Individual
ANANT KUMARIE NISCHAL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PHD-IMD, P.A
Contact information
Practice address
1478 VICTORY BLVD, STATEN ISLAND, NY 10301-3915
(718) 442-3434
Mailing address
1478 VICTORY BLVD, STATEN ISLAND, NY 10301-3915
(718) 442-3434
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
004743
NY
363AM0700X
Medical Physician Assistant
Primary
25MP00118500
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
178267
MEDICARE PTAN
NJ
01
—
25MP00118500
NJ LICENCE
NJ
Enumeration date
12/14/2007
Last updated
05/22/2014
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