Healthcare Provider Details

I. General information

NPI: 1104284835
Provider Name (Legal Business Name): IVAN DENKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 FRANKFORD AVE
PHILADELPHIA PA
19124-3602
US

IV. Provider business mailing address

432 N 6TH ST
PHILADELPHIA PA
19123-4004
US

V. Phone/Fax

Practice location:
  • Phone: 215-744-1302
  • Fax: 215-744-2544
Mailing address:
  • Phone: 215-925-2400
  • Fax: 215-925-9162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP015880
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number33 340355
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN663483
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR17659800
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22 710754
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: