=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306592068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALBERTO BAJANA I
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2022
-----------------------------------------------------
Last Update Date | 02/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 WAKEFIELD AVE
-----------------------------------------------------
City | YONKERS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10704-4210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-484-7460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 WAKEFIELD AVE
-----------------------------------------------------
City | YONKERS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10704-4210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-484-7460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 36879
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------