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General NPI Number Information
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NPI Number | 1124410303
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Entity Type | Individual
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Provider Name | KEVIN BOGUE NURSE PRACTITIONER
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Gender | Male
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Dates
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Enumeration Date | 02/25/2015
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Last Update Date | 02/05/2016
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Provider Practice Location Address
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Address Line | 1 PENN PLZ 8TH FLOOR
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City | NEW YORK
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State | NY
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Zip | 10119-0002
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Country | US
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Telephone | 646-771-2206
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Fax | 844-290-6670
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Provider Business Mailing Address
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Address Line | 225 E 79TH ST APT 8D
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City | NEW YORK
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State | NY
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Zip | 10075-0827
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Country | US
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Telephone | 917-804-7966
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Fax |
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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 | 307208
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License Number State | NY
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