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General NPI Number Information
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NPI Number | 1346962776
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Entity Type | Individual
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Provider Name | SERGEY VASSILEVICH NP
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Gender | Male
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Dates
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Enumeration Date | 09/13/2022
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Last Update Date | 09/13/2022
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Provider Practice Location Address
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Address Line | 3727 AMBOY RD
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City | STATEN ISLAND
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State | NY
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Zip | 10308-2519
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Country | US
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Telephone | 347-841-2663
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Fax | 718-691-4947
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Provider Business Mailing Address
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Address Line | 3727 AMBOY RD
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City | STATEN ISLAND
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State | NY
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Zip | 10308-2519
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Country | US
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Telephone | 347-841-2663
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Fax | 718-691-4947
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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 | 310898
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License Number State | NY
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