1336550904 NPI number — MRS. ROBERTA BUCKLEY MANSEN FNP

Table of content: MRS. ROBERTA BUCKLEY MANSEN FNP (NPI 1336550904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336550904 NPI number — MRS. ROBERTA BUCKLEY MANSEN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANSEN
Provider First Name:
ROBERTA
Provider Middle Name:
BUCKLEY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336550904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2125 RIVER RD
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
SCHENECTADY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12309-1135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-382-8350
Provider Business Mailing Address Fax Number:
518-382-0345

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2125 RIVER RD
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
SCHENECTADY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12309-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-382-8350
Provider Business Practice Location Address Fax Number:
518-382-0345
Provider Enumeration Date:
05/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  F337968-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: RN244146 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: F337968 . This is a "LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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