Provider Demographics
NPI:1457750200
Name:ITTAN, SANJU PADIYEDATHU (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SANJU
Middle Name:PADIYEDATHU
Last Name:ITTAN
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 N MAIN ST APT 26B
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-3811
Mailing Address - Country:US
Mailing Address - Phone:845-709-0173
Mailing Address - Fax:
Practice Address - Street 1:1825 EASTCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2301
Practice Address - Country:US
Practice Address - Phone:845-709-0173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338336363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily