Provider Demographics
NPI:1942331475
Name:MAHR, KIMBERLY FOX (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:FOX
Last Name:MAHR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 CHURCHILL LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-2543
Mailing Address - Country:US
Mailing Address - Phone:315-682-4236
Mailing Address - Fax:
Practice Address - Street 1:550 HARRISON ST
Practice Address - Street 2:SUITE 230
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3096
Practice Address - Country:US
Practice Address - Phone:315-472-4424
Practice Address - Fax:315-475-8056
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY442937367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY442937OtherLICENSE
NY442937OtherLICENSE