Provider Demographics
NPI:1508442567
Name:YUDHISTIRA, BRIAN (NP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:YUDHISTIRA
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 1:210 WAVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1056
Mailing Address - Country:US
Mailing Address - Phone:347-229-3939
Mailing Address - Fax:
Practice Address - Street 1:3176 ABBOTT RD STE 800
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1069
Practice Address - Country:US
Practice Address - Phone:716-391-5700
Practice Address - Fax:716-240-9878
Is Sole Proprietor?:No
Enumeration Date:2021-03-21
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY752585163WP0808X
NY403375363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health