Basic Information
| Provider Information | |||||||||
| NPI: | 1285284992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEROMINOW | ||||||||
| FirstName: | LARISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WATER STREET | ||||||||
| Address2: | 2ND FLOOR CRED DEPT | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100410010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802888 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 4771 HYLAN BLVD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103126315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189488200 | ||||||||
| FaxNumber: | 7184202718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2019 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | F30911-01 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.