Provider Demographics
NPI:1295425510
Name:SOLOMOS, MICHELLE EGOAVIL
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:EGOAVIL
Last Name:SOLOMOS
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 1:182 RUNNYMEDE RD
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-8117
Mailing Address - Country:US
Mailing Address - Phone:908-377-8773
Mailing Address - Fax:
Practice Address - Street 1:1283 YORK AVENUE
Practice Address - Street 2:15TH FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065
Practice Address - Country:US
Practice Address - Phone:646-697-6409
Practice Address - Fax:646-697-7800
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY350576363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program