Basic Information
| Provider Information | |||||||||
| NPI: | 1952929200 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARNCROSS | ||||||||
| FirstName: | JODIE | ||||||||
| MiddleName: | DANIELLE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 SALINA MEADOWS PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132124516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154642000 | ||||||||
| FaxNumber: | 3154642010 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 PRESIDENTIAL PLAZA | ||||||||
| Address2: | 1ST FL | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645210 | ||||||||
| FaxNumber: | 3154642141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2020 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F346088-01 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LX0001X | 346088 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 06179193 | 05 | NY | MEDICAID |