MEDICARE: JESSE TAYLOR BUA PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F407602-01	NY

General Provider Information

NPI Number	:	1376379446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE TAYLOR BUA PMHNP-BC

Provider Business Mailing Address
First Line	:	315 ATLANTIC AVE APT 2P
Second Line	:
City	:	EAST ROCKAWAY
State	:	NY
Zip	:	11518-1103
Country	:	US
Telephone Number	:	516-330-7724
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 JERICHO TPKE STE 216
Second Line	:
City	:	SYOSSET
State	:	NY
Zip	:	11791-4538
Country	:	US
Telephone Number	:	844-443-2563
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2024
Last Update Date	:	03/16/2026

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