Provider Demographics
NPI:1316912371
Name:STOLTZMAN, SUSAN M (ANP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:STOLTZMAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 SALINA MEADOWS PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4516
Mailing Address - Country:US
Mailing Address - Phone:315-464-2000
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:3448 ROUTE 31
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027
Practice Address - Country:US
Practice Address - Phone:315-622-6595
Practice Address - Fax:315-622-3298
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX465376363L00000X
NY382631363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113199704Medicaid
TX113199704Medicaid
TX87N429Medicare ID - Type Unspecified