Provider Demographics
NPI:1649819616
Name:EBOL, MEDARDO OCASIONES JR (RN)
Entity type:Individual
Prefix:
First Name:MEDARDO
Middle Name:OCASIONES
Last Name:EBOL
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 WESTCHESTER AVE UNIT 110
Mailing Address - Street 2:
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-3619
Mailing Address - Country:US
Mailing Address - Phone:914-473-1039
Mailing Address - Fax:
Practice Address - Street 1:KIRBY FORENSIC PSYCHIATRIC CENTER
Practice Address - Street 2:WARDS ISLAND COMPLEX
Practice Address - City:MANHATTAN
Practice Address - State:NY
Practice Address - Zip Code:10035-6095
Practice Address - Country:US
Practice Address - Phone:914-646-6800
Practice Address - Fax:914-646-6892
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY637484163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult