MEDICARE: MS. TINA LESEVIC FNP

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	363LF0000X	Family Nurse Practitioner	336743	NY

General Provider Information

NPI Number	:	1861784191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TINA LESEVIC FNP

Provider Business Mailing Address
First Line	:	44 MYRTLE AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10310-2057
Country	:	US
Telephone Number	:	917-572-4870
Fax Number	:

Provider Business Practice Location Address
First Line	:	44 MYRTLE AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10310-2057
Country	:	US
Telephone Number	:	917-572-4870
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	05/05/2011

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