Provider Demographics
NPI:1659619666
Name:JEGANATHAN, PUSHPAMALAR
Entity Type:Individual
Prefix:
First Name:PUSHPAMALAR
Middle Name:
Last Name:JEGANATHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8313 256TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1611
Mailing Address - Country:US
Mailing Address - Phone:718-470-2305
Mailing Address - Fax:
Practice Address - Street 1:8313 256TH ST
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11004-1611
Practice Address - Country:US
Practice Address - Phone:718-470-2305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY655982163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse