Provider Demographics
NPI:1457830218
Name:AN, SUJIN
Entity Type:Individual
Prefix:
First Name:SUJIN
Middle Name:
Last Name:AN
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 1:2707 CRESTON AVE APT 6L
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2707 CRESTON AVE APT 6L
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3625
Practice Address - Country:US
Practice Address - Phone:929-429-7357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-11
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY716154-1163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY66163783Medicaid