Provider Demographics
NPI:1083980296
Name:BOODRAM, RADHA MAGDALEEN (ACUTE CARE NP)
Entity Type:Individual
Prefix:
First Name:RADHA
Middle Name:MAGDALEEN
Last Name:BOODRAM
Suffix:
Gender:F
Credentials:ACUTE CARE NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 MARCUS AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-2057
Mailing Address - Country:US
Mailing Address - Phone:516-472-6012
Mailing Address - Fax:
Practice Address - Street 1:1991 MARCUS AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2057
Practice Address - Country:US
Practice Address - Phone:516-472-6012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5107311163W00000X
NY4306021363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse