Provider Demographics
NPI:1205157419
Name:BURGESS, CORRIE L (FNP)
Entity type:Individual
Prefix:
First Name:CORRIE
Middle Name:L
Last Name:BURGESS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2866
Mailing Address - Country:US
Mailing Address - Phone:315-701-2550
Mailing Address - Fax:315-701-2551
Practice Address - Street 1:739 IRVING AVE STE 600
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1663
Practice Address - Country:US
Practice Address - Phone:315-701-2550
Practice Address - Fax:315-701-2551
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336372-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03534470Medicaid
NYJ400082385Medicare UPIN