Provider Demographics
NPI:1184726341
Name:MACBLANE, MARY ELIZABETH (PNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:MACBLANE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5235 BEAR RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-1213
Mailing Address - Country:US
Mailing Address - Phone:315-464-5259
Mailing Address - Fax:315-464-6398
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:PEDIATRICS
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-5259
Practice Address - Fax:315-464-6398
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY325340-1163WP0200X
NYF380760-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WP0200XNursing Service ProvidersRegistered NursePediatrics
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02218940Medicaid
NY02218940Medicaid