Healthcare Provider Details

I. General information

NPI: 1740647478
Provider Name (Legal Business Name): OPHIA SEWER AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 E 23RD ST
NEW YORK NY
10010-5011
US

IV. Provider business mailing address

240 COZINE AVE APT 6H
BROOKLYN NY
11207-8871
US

V. Phone/Fax

Practice location:
  • Phone: 212-686-7500
  • Fax:
Mailing address:
  • Phone: 718-924-6445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number307060
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: