Healthcare Provider Details

I. General information

NPI: 1487419149
Provider Name (Legal Business Name): JASON T EPHRAIM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22215 NORTHERN BLVD
BAYSIDE NY
11361-3678
US

IV. Provider business mailing address

11045 QUEENS BLVD APT 714
FOREST HILLS NY
11375-5504
US

V. Phone/Fax

Practice location:
  • Phone: 631-690-5155
  • Fax:
Mailing address:
  • Phone: 347-558-1661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number923967
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: