Healthcare Provider Details

I. General information

NPI: 1093659351
Provider Name (Legal Business Name): ADE'HMAR JEDIAH DEANDRES NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 MOUNT EDEN PKWY
BRONX NY
10457-7605
US

IV. Provider business mailing address

174 MOUNT EDEN PKWY
BRONX NY
10457-7605
US

V. Phone/Fax

Practice location:
  • Phone: 718-885-6593
  • Fax:
Mailing address:
  • Phone: 718-885-6593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4243062
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number359403
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: