Provider Demographics
NPI:1902105273
Name:FETZER, NICOLE MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:FETZER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2337
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-2337
Mailing Address - Country:US
Mailing Address - Phone:315-422-6705
Mailing Address - Fax:315-422-3909
Practice Address - Street 1:225 GREENFIELD PKWY STE 105
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088
Practice Address - Country:US
Practice Address - Phone:315-451-6911
Practice Address - Fax:315-451-1540
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY543801207R00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine