Healthcare Provider Details

I. General information

NPI: 1093311409
Provider Name (Legal Business Name): BASSEY ULO ENYENIHI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 12/10/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 WADING RIVER ROAD SUITE 8
MANORVILLE NY
11949-1194
US

IV. Provider business mailing address

17 BIRCHGROVE DR
CENTRAL ISLIP NY
11722-1904
US

V. Phone/Fax

Practice location:
  • Phone: 631-716-5410
  • Fax:
Mailing address:
  • Phone: 516-983-0893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF343092-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: