Provider Demographics
NPI:1053367573
Name:MODRAK, GENEVA (CRNA)
Entity type:Individual
Prefix:
First Name:GENEVA
Middle Name:
Last Name:MODRAK
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 2005
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4505
Mailing Address - Country:US
Mailing Address - Phone:315-449-0513
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:10 HAGEN DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2660
Practice Address - Country:US
Practice Address - Phone:585-367-8200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY419342367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered