Provider Demographics
NPI:1780673228
Name:THANGAVELU, EBENEZER PREMKUMAR (NP)
Entity Type:Individual
Prefix:MR
First Name:EBENEZER
Middle Name:PREMKUMAR
Last Name:THANGAVELU
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 SOUTH 9TH STREET
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757
Mailing Address - Country:US
Mailing Address - Phone:631-957-1859
Mailing Address - Fax:
Practice Address - Street 1:143 S 9TH ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4523
Practice Address - Country:US
Practice Address - Phone:516-983-5754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF 302708-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health