Provider Demographics
NPI:1780069005
Name:POLLARD, NASTASHA
Entity type:Individual
Prefix:
First Name:NASTASHA
Middle Name:
Last Name:POLLARD
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:PO BOX 5024
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5024
Mailing Address - Country:US
Mailing Address - Phone:800-627-4470
Mailing Address - Fax:843-806-4742
Practice Address - Street 1:109 E 89TH ST APT 3E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1531
Practice Address - Country:US
Practice Address - Phone:845-642-2473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY674056163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1780069005Medicaid