Healthcare Provider Details

I. General information

NPI: 1164933487
Provider Name (Legal Business Name): O.B. ADULT HEALTH NURSE PRACTITIONER SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 11/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 BROAD ST
STATEN ISLAND NY
10304-2105
US

IV. Provider business mailing address

224 OSGOOD AVE
STATEN ISLAND NY
10304-3607
US

V. Phone/Fax

Practice location:
  • Phone: 917-374-9180
  • Fax: 718-448-7263
Mailing address:
  • Phone:
  • Fax: 718-448-7263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberF307489
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF307489
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number573342
License Number StateNY

VIII. Authorized Official

Name: OLASUNKANMI BHADMUS
Title or Position: ASSISTANT DIRECTOR
Credential: NURSE PRACTITIONER
Phone: 917-374-9180