Provider Demographics
NPI:1235645649
Name:LARA, FERDINAND ESTEBAN (RN)
Entity Type:Individual
Prefix:
First Name:FERDINAND
Middle Name:ESTEBAN
Last Name:LARA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:FERDINAND
Other - Middle Name:ESTEBAN
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:777 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3409
Mailing Address - Country:US
Mailing Address - Phone:718-667-2648
Mailing Address - Fax:718-668-8099
Practice Address - Street 1:777 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3409
Practice Address - Country:US
Practice Address - Phone:718-667-2648
Practice Address - Fax:718-668-8099
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY474827-1163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty