Basic Information
Provider Information | |||||||||
NPI: | 1922500982 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERTOLINO | ||||||||
FirstName: | JIAN XIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AGPCNP/BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5620 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FLUSHING | ||||||||
State: | NY | ||||||||
PostalCode: | 113555046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186701837 | ||||||||
FaxNumber: | 7189611853 | ||||||||
Practice Location | |||||||||
Address1: | 5620 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FLUSHING | ||||||||
State: | NY | ||||||||
PostalCode: | 113555046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186701837 | ||||||||
FaxNumber: | 7189611853 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2018 | ||||||||
LastUpdateDate: | 08/14/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | F308582-1 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 05133835 | 05 | NY |   | MEDICAID |