Provider Demographics
NPI:1407352370
Name:NEBO, EDMUND C (NP)
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:C
Last Name:NEBO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 E NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-6015
Mailing Address - Country:US
Mailing Address - Phone:917-940-1980
Mailing Address - Fax:
Practice Address - Street 1:1111 MARCUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1221
Practice Address - Country:US
Practice Address - Phone:917-940-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-01
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308605363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health