Provider Demographics
NPI:1770903148
Name:IDDRIS, SWADA (RN)
Entity type:Individual
Prefix:
First Name:SWADA
Middle Name:
Last Name:IDDRIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 WILLIAMSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2507
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:
Practice Address - Street 1:1434 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2507
Practice Address - Country:US
Practice Address - Phone:718-618-0401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY682460163W00000X
NYF421449363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse