Provider Demographics
NPI:1326533696
Name:BRILLANTES, GEVI DOMINIQUE (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:GEVI DOMINIQUE
Middle Name:
Last Name:BRILLANTES
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6014 59TH DR
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-3416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2613 21ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-3544
Practice Address - Country:US
Practice Address - Phone:718-626-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308639363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health