Provider Demographics
NPI:1396769048
Name:WILBURN, JUDY NORMAN (FNP)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:NORMAN
Last Name:WILBURN
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 1:1407 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2707
Mailing Address - Country:US
Mailing Address - Phone:315-334-4662
Mailing Address - Fax:
Practice Address - Street 1:ROME CBOC OF THE SYRACUSE VA
Practice Address - Street 2:125 BROOKLEY AVE.
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13441
Practice Address - Country:US
Practice Address - Phone:315-334-7100
Practice Address - Fax:315-334-7171
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330964-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYUAD000Medicare UPIN