Healthcare Provider Details

I. General information

NPI: 1205459534
Provider Name (Legal Business Name): SHYAN INDERA JAGDEO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2020
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3224 ANCHOR DR
FAR ROCKAWAY NY
11691-1602
US

IV. Provider business mailing address

3224 ANCHOR DR
FAR ROCKAWAY NY
11691-1602
US

V. Phone/Fax

Practice location:
  • Phone: 718-450-6604
  • Fax: 516-531-8944
Mailing address:
  • Phone: 718-450-6604
  • Fax: 516-531-8944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number309775
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: