Basic Information
| Provider Information | |||||||||
| NPI: | 1649221367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISE WOMAN OB/GYN, PC | ||||||||
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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: | 3154761792 | ||||||||
| Practice Location | |||||||||
| Address1: | 172 CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136013602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157826262 | ||||||||
| FaxNumber: | 3157825181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | HAWKINS | ||||||||
| AuthorizedOfficialFirstName: | NANCI | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3157826262 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 02751077 | 05 | NY | MEDICAID |