Provider Demographics
NPI:1023291887
Name:NISCHAL, ANANT KUMARIE (PHD-IMD, PA)
Entity type:Individual
Prefix:
First Name:ANANT
Middle Name:KUMARIE
Last Name:NISCHAL
Suffix:
Gender:F
Credentials:PHD-IMD, PA
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:
Other - Last Name:NISCHAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD-IMD, PA
Mailing Address - Street 1:1478 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3915
Mailing Address - Country:US
Mailing Address - Phone:718-442-3434
Mailing Address - Fax:
Practice Address - Street 1:1478 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3915
Practice Address - Country:US
Practice Address - Phone:718-442-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004743363AM0700X
NJ25MP00118500363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ178267OtherMEDICARE PTAN
NJ25MP00118500OtherNJ LICENCE
NJ178267OtherMEDICARE PTAN