Provider Demographics
NPI:1619299872
Name:JEONG, PETER (CNP)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:JEONG
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WATER STREET
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0010
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:52 DUANE ST
Practice Address - Street 2:ADVANTAGE CARE PHYSICIANS
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-1207
Practice Address - Country:US
Practice Address - Phone:718-680-4693
Practice Address - Fax:646-751-6909
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.11203-NP363LA2200X
OHCOA.11203 -NP363LF0000X
NYF340501-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health