Provider Demographics
NPI:1336439736
Name:PLASTICWALA, FAUZAN (LPN)
Entity Type:Individual
Prefix:MR
First Name:FAUZAN
Middle Name:
Last Name:PLASTICWALA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 FULTON AVE
Mailing Address - Street 2:APT. # 536
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-4102
Mailing Address - Country:US
Mailing Address - Phone:917-715-0631
Mailing Address - Fax:
Practice Address - Street 1:451 FULTON AVE
Practice Address - Street 2:APT. # 536
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4102
Practice Address - Country:US
Practice Address - Phone:917-715-0631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303494164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse