Provider Demographics
NPI:1780942458
Name:WARDHANA, YOHANNES
Entity type:Individual
Prefix:
First Name:YOHANNES
Middle Name:
Last Name:WARDHANA
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 1:8007 45TH AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-3544
Mailing Address - Country:US
Mailing Address - Phone:917-652-5846
Mailing Address - Fax:
Practice Address - Street 1:8007 45TH AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-3544
Practice Address - Country:US
Practice Address - Phone:917-652-5846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307334164W00000X
NY700163-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse