Provider Demographics
NPI:1083082119
Name:CALLADA, RONN MATEO
Entity Type:Individual
Prefix:
First Name:RONN
Middle Name:MATEO
Last Name:CALLADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 HUDSON ST
Mailing Address - Street 2:STE 2
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-5644
Mailing Address - Country:US
Mailing Address - Phone:646-779-4311
Mailing Address - Fax:
Practice Address - Street 1:298 5TH AVE
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4522
Practice Address - Country:US
Practice Address - Phone:646-779-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-06
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306620363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400131158Medicare PIN