Healthcare Provider Details

I. General information

NPI: 1114440047
Provider Name (Legal Business Name): GINA BRANDEIS PUTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2017
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

1275 YORK AVE
NEW YORK NY
10065-6007
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF308074-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: