Provider Demographics
NPI:1265906085
Name:GODHWANI, PUJA KAKAR (AGNP)
Entity type:Individual
Prefix:MRS
First Name:PUJA
Middle Name:KAKAR
Last Name:GODHWANI
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 FOXRUN CT
Mailing Address - Street 2:
Mailing Address - City:PORT JEFF STA
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1386
Mailing Address - Country:US
Mailing Address - Phone:516-998-6505
Mailing Address - Fax:
Practice Address - Street 1:6144 NY-25A
Practice Address - Street 2:BUILDING C SUITE 13
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792
Practice Address - Country:US
Practice Address - Phone:631-886-2844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308923-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health