Healthcare Provider Details

I. General information

NPI: 1689002206
Provider Name (Legal Business Name): JASODA DHUPAN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2384 ATLANTIC AVE
BROOKLYN NY
11233-3402
US

IV. Provider business mailing address

10702 103RD AVE
OZONE PARK NY
11417-1805
US

V. Phone/Fax

Practice location:
  • Phone: 718-272-6074
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF310167-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: