Provider Demographics
NPI:1205213337
Name:SHAO-BERKERY, DOMINICK ANTHONY
Entity type:Individual
Prefix:
First Name:DOMINICK
Middle Name:ANTHONY
Last Name:SHAO-BERKERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DOMINICK
Other - Middle Name:ANTHONY
Other - Last Name:BERKERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:622 WEST 168TH STREET
Mailing Address - Street 2:PH 505, 5TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:415-999-6543
Mailing Address - Fax:
Practice Address - Street 1:66 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:WALDWICK
Practice Address - State:NJ
Practice Address - Zip Code:07463-2210
Practice Address - Country:US
Practice Address - Phone:415-999-6543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY598181163W00000X
CA95000377367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse