Healthcare Provider Details

I. General information

NPI: 1932982568
Provider Name (Legal Business Name): THOMAS OBRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 PARK AVE APT 1C
NEW YORK NY
10128-1712
US

IV. Provider business mailing address

3107 31ST AVE APT 3A
ASTORIA NY
11106-2406
US

V. Phone/Fax

Practice location:
  • Phone: 917-209-3864
  • Fax:
Mailing address:
  • Phone: 347-576-9428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number802916
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: