Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LA2200X | Nurse Practitioner - Adult Health | F302146-1 | NY |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | F333173-1 | NY |
NPI | 1013912153 |
---|---|
Provider Name | Alida Anne Dejong |
First Address | Syracuse, NY 13203-2730 |
Second Address | Syracuse, NY 13203-2730 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2005 |
Last Update Date | 01/12/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02629216 | (05) | NY |
P80013 | (02) | NY |