Provider Demographics
NPI:1477311264
Name:EUSTAQUIO, LOREN CRUZ (NP)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:CRUZ
Last Name:EUSTAQUIO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 CARLTON AVE APT 609
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-4471
Mailing Address - Country:US
Mailing Address - Phone:914-279-9709
Mailing Address - Fax:
Practice Address - Street 1:424 E 34TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4901
Practice Address - Country:US
Practice Address - Phone:914-279-9709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF432747-01363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty