Basic Information
| Provider Information | |||||||||
| NPI: | 1518370055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATSIKOS | ||||||||
| FirstName: | JOHANIS | ||||||||
| MiddleName: | THAMAR | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 W 168TH ST # 4 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123057340 | ||||||||
| FaxNumber: | 2123056891 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 FORT WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123057340 | ||||||||
| FaxNumber: | 2123056891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2014 | ||||||||
| LastUpdateDate: | 05/09/2019 | ||||||||
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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 | 163W00000X | 677151 | NY | N | Nursing Service Providers | Registered Nurse | 363L00000X | F308049-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | F308049 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.