Provider Demographics
NPI:1992242663
Name:PREVENTIVE FAMILY HEALTHCARE FNPC, PLLC
Entity type:Organization
Organization Name:PREVENTIVE FAMILY HEALTHCARE FNPC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:SCOT
Authorized Official - Last Name:GILFUS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:315-689-0001
Mailing Address - Street 1:247 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:13060-8706
Mailing Address - Country:US
Mailing Address - Phone:315-689-0001
Mailing Address - Fax:315-277-5311
Practice Address - Street 1:247 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:13060-8706
Practice Address - Country:US
Practice Address - Phone:315-689-0001
Practice Address - Fax:315-277-5311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04458706Medicaid