Healthcare Provider Details

I. General information

NPI: 1831713163
Provider Name (Legal Business Name): DAVE AMARASENA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 TYSENS LN
STATEN ISLAND NY
10306-5621
US

IV. Provider business mailing address

745 TYSENS LN
STATEN ISLAND NY
10306-5621
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-3234
  • Fax:
Mailing address:
  • Phone: 718-667-3234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF345844-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: