Healthcare Provider Details

I. General information

NPI: 1124775416
Provider Name (Legal Business Name): ALEXANDER OBRADOVIC PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N VILLAGE AVE STE 27
ROCKVILLE CENTRE NY
11570-3712
US

IV. Provider business mailing address

38 PEACH TREE COMMON
ST CATHARINES ONTARIO
L2N0B6
CA

V. Phone/Fax

Practice location:
  • Phone: 416-802-7277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number403934
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: