Provider Demographics
NPI:1356558589
Name:FADERAN, THELMA VILLAR
Entity type:Individual
Prefix:MISS
First Name:THELMA
Middle Name:VILLAR
Last Name:FADERAN
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 1:30 WATERSIDE PLAZA
Mailing Address - Street 2:23C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-2625
Mailing Address - Country:US
Mailing Address - Phone:212-725-2923
Mailing Address - Fax:212-725-2923
Practice Address - Street 1:30 WATERSIDE PLZ
Practice Address - Street 2:23C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-2622
Practice Address - Country:US
Practice Address - Phone:212-725-2923
Practice Address - Fax:212-725-2923
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5186830363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5186830OtherNP LICENSE NUMBER