Healthcare Provider Details

I. General information

NPI: 1093211351
Provider Name (Legal Business Name): IVELISE A PEGUERO CLINICAL LAB TECH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE RM 1208
NEW YORK NY
10029-7491
US

IV. Provider business mailing address

1901 1ST AVE RM 1208
NEW YORK NY
10029-7491
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6271
  • Fax:
Mailing address:
  • Phone: 212-423-6271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number002964-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: