Basic Information
| Provider Information | |||||||||
| NPI: | 1215096482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROVO | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | GNPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1208 DRIVING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145131057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153592640 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1208 DRIVING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145131057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153592640 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 01/06/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F3041711 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | F3403661 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.