Provider Demographics
NPI:1679214779
Name:ANTONIO BALDERA, EDITH
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:ANTONIO BALDERA
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 1:9724 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-2145
Mailing Address - Country:US
Mailing Address - Phone:917-817-6347
Mailing Address - Fax:
Practice Address - Street 1:101 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2499
Practice Address - Country:US
Practice Address - Phone:401-274-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program