Provider Demographics
NPI:1558021121
Name:MODAFFERI, AMBER (CRNA, RN)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:MODAFFERI
Suffix:
Gender:F
Credentials:CRNA, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-1352
Mailing Address - Country:US
Mailing Address - Phone:315-561-3068
Mailing Address - Fax:
Practice Address - Street 1:1001 WEST ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-9703
Practice Address - Country:US
Practice Address - Phone:315-493-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138545367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered