MEDICARE: SP NURSE PRACTITIONER IN ADULT HEALTH PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1316654353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SP NURSE PRACTITIONER IN ADULT HEALTH PC

Provider Business Mailing Address
First Line	:	428 E HARRISON ST
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-2346
Country	:	US
Telephone Number	:	212-961-6767
Fax Number	:

Provider Business Practice Location Address
First Line	:	428 E HARRISON ST
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-2346
Country	:	US
Telephone Number	:	212-961-6767
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SEDA ANGELINA PORT
Credential	:	NP
Telephone Number	:	212-961-6767

Provider Enumeration Date	:	10/31/2022
Last Update Date	:	03/30/2023

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