Provider Demographics
NPI:1922500982
Name:BERTOLINO, JIAN XIN (AGPCNP/BC)
Entity Type:Individual
Prefix:MRS
First Name:JIAN XIN
Middle Name:
Last Name:BERTOLINO
Suffix:
Gender:F
Credentials:AGPCNP/BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5046
Mailing Address - Country:US
Mailing Address - Phone:718-670-1837
Mailing Address - Fax:718-961-1853
Practice Address - Street 1:5620 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5046
Practice Address - Country:US
Practice Address - Phone:718-670-1837
Practice Address - Fax:718-961-1853
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308582-1363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05133835Medicaid