Provider Demographics
NPI:1356542401
Name:BOLAND, DEBORAH MCCARTHY (RN MS CPNP FPMHNP)
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:MCCARTHY
Last Name:BOLAND
Suffix:
Gender:F
Credentials:RN MS CPNP FPMHNP
Other - Prefix:MS
Other - First Name:DEBORAH
Other - Middle Name:ANN
Other - Last Name:MCCARTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN MS CPNP FPMHNP
Mailing Address - Street 1:635 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2226
Mailing Address - Country:US
Mailing Address - Phone:315-671-2959
Mailing Address - Fax:315-422-0948
Practice Address - Street 1:635 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2226
Practice Address - Country:US
Practice Address - Phone:315-671-2964
Practice Address - Fax:315-671-2943
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3204651163W00000X
NYF3803031363LP0200X
NYF401476363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02745426Medicaid