Healthcare Provider Details

I. General information

NPI: 1982926424
Provider Name (Legal Business Name): MR. NICHOLAS EDWARD BOURKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 GREENWAY TER APT 15W
FOREST HILLS NY
11375-5267
US

IV. Provider business mailing address

150 GREENWAY TERRACE APT 15W
FOREST HILLS NY
11375
US

V. Phone/Fax

Practice location:
  • Phone: 917-573-9849
  • Fax:
Mailing address:
  • Phone: 917-573-9849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number049169
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: