Healthcare Provider Details

I. General information

NPI: 1790031458
Provider Name (Legal Business Name): GLORIA P ESCOBAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9131 QUEENS BLVD
ELMHURST NY
11373-5555
US

IV. Provider business mailing address

9131 QUEENS BLVD
ELMHURST NY
11373-5555
US

V. Phone/Fax

Practice location:
  • Phone: 718-819-2830
  • Fax:
Mailing address:
  • Phone: 718-819-2830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number10 293512
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: