Provider Demographics
NPI:1205980109
Name:SORBER, GWEN M (NP)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:M
Last Name:SORBER
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 1:104 UNION AVE
Mailing Address - Street 2:SUITE 804
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1843
Mailing Address - Country:US
Mailing Address - Phone:315-703-5049
Mailing Address - Fax:315-703-5079
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-448-5111
Practice Address - Fax:315-703-5049
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302368363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2073792Medicaid
NYP07551Medicare UPIN
NY2073792Medicaid
NY53145AMedicare PIN
NYCC0729Medicare PIN