Healthcare Provider Details

I. General information

NPI: 1982421871
Provider Name (Legal Business Name): MARCUS ENGRAM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 CLARKSON AVE
BROOKLYN NY NY
11203
US

IV. Provider business mailing address

244 EDGEWATER ST
STATEN ISLAND NY
10305-4929
US

V. Phone/Fax

Practice location:
  • Phone: 718-221-7700
  • Fax:
Mailing address:
  • Phone: 315-507-1805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number877887
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: