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General NPI Number Information
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NPI Number | 1033379540
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Entity Type | Individual
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Provider Name | KENNETH ALLEN MOBERG NURSE PRACTITIONER
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Gender | Male
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Dates
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Enumeration Date | 06/10/2008
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Last Update Date | 08/27/2013
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Provider Practice Location Address
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Address Line | 121B WEST 20TH STREET VILLAGE DIAGNOSTIC & TREATMENT CENTER
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City | NEW YORK
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State | NY
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Zip | 10011
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Country | US
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Telephone | 212-337-9290
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Fax | 212-337-9275
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Provider Business Mailing Address
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Address Line | 121B WEST 20TH STREET VILLAGE DIAGNOSTIC & TREATMENT CENTER
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City | NEW YORK
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State | NY
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Zip | 10011
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Country | US
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Telephone | 212-337-9290
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Fax | 212-337-9275
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | F302611-1
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License Number State | NY
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