Provider Demographics
NPI:1962465377
Name:BAZEN, PHYLLIS (NP)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:
Last Name:BAZEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 S SALINA ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3527
Mailing Address - Country:US
Mailing Address - Phone:315-476-7921
Mailing Address - Fax:315-474-1448
Practice Address - Street 1:819 S SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3536
Practice Address - Country:US
Practice Address - Phone:315-476-7921
Practice Address - Fax:315-475-1448
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301006363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02184912Medicaid
NYP00228Medicare UPIN
NY02184912Medicaid