1356624159 NPI number — MRS. PURA VASQUEZ DIAZ

Table of content: MRS. PURA VASQUEZ DIAZ (NPI 1356624159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356624159 NPI number — MRS. PURA VASQUEZ DIAZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VASQUEZ DIAZ
Provider First Name:
PURA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DIAZ
Provider Other First Name:
PURA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1356624159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 LEXINGTON AVE , 14 FL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-398-3216
Provider Business Mailing Address Fax Number:
212-524-5163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-342-1033
Provider Business Practice Location Address Fax Number:
845-344-5631
Provider Enumeration Date:
09/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  F335491-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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