Provider Demographics
NPI:1770330524
Name:GJECI, SPARTAK
Entity type:Individual
Prefix:
First Name:SPARTAK
Middle Name:
Last Name:GJECI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1476
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10925-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1476
Practice Address - Street 2:
Practice Address - City:GREENWOOD LAKE
Practice Address - State:NY
Practice Address - Zip Code:10925-1476
Practice Address - Country:US
Practice Address - Phone:914-666-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY353384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily