Provider Demographics
NPI:1417301094
Name:KAGANOVSKAYA, MARCEL (FNP)
Entity Type:Individual
Prefix:
First Name:MARCEL
Middle Name:
Last Name:KAGANOVSKAYA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W KINGSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3904
Mailing Address - Country:US
Mailing Address - Phone:570-540-2590
Mailing Address - Fax:
Practice Address - Street 1:131 OVERPECK AVE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07660-1855
Practice Address - Country:US
Practice Address - Phone:201-667-2197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF404375363LP0808X
NJ26NJ01158200363LP0808X
NY340371363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily