Provider Demographics
NPI:1144417635
Name:EVANGELISTA, MARIA CARMELA YU SAM (NP)
Entity Type:Individual
Prefix:
First Name:MARIA CARMELA
Middle Name:YU SAM
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARIA CARMELA
Other - Middle Name:EVANGELISTA
Other - Last Name:DACANAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:622 W 168TH ST
Mailing Address - Street 2:PH 11
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-1566
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:PH 11
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-1566
Practice Address - Fax:212-305-1457
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263257363LA2200X
NY304724363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY304724OtherNY STATE NP REGISTRATION
NYA400002705Medicare UPIN