Basic Information
| Provider Information | |||||||||
| NPI: | 1811914369 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ADVERSARIO | ||||||||
| FirstName: | EDEN | ||||||||
| MiddleName: | FLORENDO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PARK AVENUE MEDICAL ASSOCIATES PC | ||||||||
| Address2: | THREE BARKER AVENUE 4TH FLOOR | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149491199 | ||||||||
| FaxNumber: | 9149491245 | ||||||||
| Practice Location | |||||||||
| Address1: | PARK AVENUE MEDICAL ASSOCIATES PC | ||||||||
| Address2: | THREE BARKER AVENUE 4TH FLOOR | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149491199 | ||||||||
| FaxNumber: | 9149491245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363L00000X | 302421 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 02168110 | 05 | NY | MEDICAID |