Provider Demographics
NPI:1124410303
Name:BOGUE, KEVIN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BOGUE
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E 79TH ST APT 8D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0827
Mailing Address - Country:US
Mailing Address - Phone:917-804-7966
Mailing Address - Fax:
Practice Address - Street 1:1 PENN PLZ
Practice Address - Street 2:8TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10119-0002
Practice Address - Country:US
Practice Address - Phone:646-771-2206
Practice Address - Fax:844-290-6670
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307208363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health