Basic Information
| Provider Information | |||||||||
| NPI: | 1497758965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COHEN | ||||||||
| FirstName: | LESTER | ||||||||
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| Credential: | C.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 WISSAHICKON AVE | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191444248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2675973600 | ||||||||
| FaxNumber: | 2675973622 | ||||||||
| Practice Location | |||||||||
| Address1: | 6120-B WOODLAND AVENUE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157274721 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 04/28/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP001023B | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1011451120005 | 05 | PA | MEDICAID |