Healthcare Provider Details

I. General information

NPI: 1417566076
Provider Name (Legal Business Name): JORDAN ROSS WALDMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 DEKALB AVE
BROOKLYN NY
11201-5493
US

IV. Provider business mailing address

3100 DENTON DR
MERRICK NY
11566-5115
US

V. Phone/Fax

Practice location:
  • Phone: 718-250-8000
  • Fax:
Mailing address:
  • Phone: 516-244-5824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number696827-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number696827
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: