Basic Information
| Provider Information | |||||||||
| NPI: | 1528511409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHN | ||||||||
| FirstName: | JEREL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S BEDFORD RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105493446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142411050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 S BEDFORD RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105493412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142411050 | ||||||||
| FaxNumber: | 9142421412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2016 | ||||||||
| LastUpdateDate: | 12/13/2017 | ||||||||
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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 | 363LF0000X | 340434 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 00547351 | 05 | NY | MEDICAID |