Provider Demographics
NPI:1265423743
Name:SNYDER, LISA SIMONETTA (RN,MSN,FNP-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SIMONETTA
Last Name:SNYDER
Suffix:
Gender:F
Credentials:RN,MSN,FNP-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:SIMONETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:134 HOMER AVE
Mailing Address - Street 2:PO BOX 628
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1206
Mailing Address - Country:US
Mailing Address - Phone:607-756-3561
Mailing Address - Fax:607-428-5142
Practice Address - Street 1:134 HOMER AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1206
Practice Address - Country:US
Practice Address - Phone:607-756-3561
Practice Address - Fax:607-428-5142
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3322590207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02057216Medicaid
NYBB8307Medicare ID - Type Unspecified
NY02057216Medicaid