Provider Demographics
NPI:1336866680
Name:SEGARRA, ANGEL ANTONIO (LPN)
Entity Type:Individual
Prefix:MR
First Name:ANGEL
Middle Name:ANTONIO
Last Name:SEGARRA
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 1:130 WOODLAWN AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-3136
Mailing Address - Country:US
Mailing Address - Phone:917-324-5533
Mailing Address - Fax:
Practice Address - Street 1:130 WOODLAWN AVE APT 1
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-3136
Practice Address - Country:US
Practice Address - Phone:917-324-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323481164W00000X
NY020730225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No164W00000XNursing Service ProvidersLicensed Practical Nurse