Basic Information
| Provider Information | |||||||||
| NPI: | 1598744880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANSEN | ||||||||
| FirstName: | MASHELLE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W FAYETTE ST | ||||||||
| Address2: | STE 400 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154721488 | ||||||||
| FaxNumber: | 3154728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 CENTRAL ST | ||||||||
| Address2: | |||||||||
| City: | MORAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131183612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154971497 | ||||||||
| FaxNumber: | 3154971490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 02/17/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F333729 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 333729 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | 333729 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02352078 | 05 | NY | MEDICAID |