Provider Demographics
NPI:1558560078
Name:BUAN-JACOMINA, ANA LIZA (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:LIZA
Last Name:BUAN-JACOMINA
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 1ST AVE
Mailing Address - Street 2:#703
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3310
Mailing Address - Country:US
Mailing Address - Phone:212-400-8477
Mailing Address - Fax:
Practice Address - Street 1:2110 1ST AVE
Practice Address - Street 2:#703
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-3310
Practice Address - Country:US
Practice Address - Phone:212-400-8477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007989-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02554227Medicaid