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General NPI Number Information
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NPI Number | 1740565753
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Entity Type | Individual
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Provider Name | JEFFREY BOURSIQUOT
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Gender | Male
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Dates
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Enumeration Date | 10/21/2011
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Last Update Date | 08/10/2016
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Provider Practice Location Address
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Address Line | 460 W 34TH ST 9TH FL
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City | NEW YORK
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State | NY
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Zip | 10001-2320
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Country | US
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Telephone | 212-273-6100
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Fax |
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Provider Business Mailing Address
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Address Line | 914 E 85TH ST 2ND FL
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City | BROOKLYN
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State | NY
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Zip | 11236-3804
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Country | US
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Telephone | 347-774-5565
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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 | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 304818
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License Number State | NY
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