Healthcare Provider Details

I. General information

NPI: 1801161278
Provider Name (Legal Business Name): SOMARIA GOBADAN REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2012
Last Update Date: 03/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 BAYCHESTER AVE
BRONX NY
10475-1756
US

IV. Provider business mailing address

700 BAYCHESTER AVE
BRONX NY
10475-1756
US

V. Phone/Fax

Practice location:
  • Phone: 718-904-5650
  • Fax: 718-904-5655
Mailing address:
  • Phone: 718-904-5650
  • Fax: 718-904-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number468687-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number468687-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: