Provider Demographics
NPI:1144846502
Name:EVERGREEN, ELIZABETH A (FNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:EVERGREEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:6846 BUCKLEY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4275
Mailing Address - Country:US
Mailing Address - Phone:315-410-6400
Mailing Address - Fax:315-410-6410
Practice Address - Street 1:930 S SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3530
Practice Address - Country:US
Practice Address - Phone:315-435-6266
Practice Address - Fax:315-234-0465
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34594364SF0001X
NY345954363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health