Provider Demographics
NPI:1629401443
Name:MOUSTAPHA, SHADIATU O (FNP)
Entity Type:Individual
Prefix:MS
First Name:SHADIATU
Middle Name:O
Last Name:MOUSTAPHA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:SHADIATU
Other - Middle Name:O
Other - Last Name:MOUSTAPHA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:3198 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1000
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:718-795-4394
Practice Address - Street 1:2015 GRAND CONCOURSE STE B
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4303
Practice Address - Country:US
Practice Address - Phone:718-299-7295
Practice Address - Fax:718-299-6797
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY621087163W00000X
NY338271363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse