Basic Information
| Provider Information | |||||||||
| NPI: | 1376124297 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NURSE PRACTITIONER IN ADULT GERONTOLOGY FAMILY AND PALLATIVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 S MAIN ST | ||||||||
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| City: | NEW CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109563353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9179152866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 WEST KINDSBRIDGE ROAD | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104680355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9179152866 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2021 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | GABRIEL | ||||||||
| AuthorizedOfficialFirstName: | JOSEPHINE | ||||||||
| AuthorizedOfficialMiddleName: | ZETILIA | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9179152866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1356367569 | 05 | NY | MEDICAID |