Provider Demographics
NPI:1245780071
Name:DUCOSTE-REFUSE, MEDJIN
Entity type:Individual
Prefix:
First Name:MEDJIN
Middle Name:
Last Name:DUCOSTE-REFUSE
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 1:21215 112TH RD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2313
Mailing Address - Country:US
Mailing Address - Phone:917-421-2947
Mailing Address - Fax:
Practice Address - Street 1:21215 112TH RD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-2313
Practice Address - Country:US
Practice Address - Phone:917-421-2947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301152164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY301152Medicaid