Provider Demographics
NPI:1811314487
Name:ETHIRAJULU, PREMA UDAYAKUMAR (NP)
Entity type:Individual
Prefix:MRS
First Name:PREMA
Middle Name:UDAYAKUMAR
Last Name:ETHIRAJULU
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:1 HEALTHY WAY
Mailing Address - Street 2:E-3
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1551
Mailing Address - Country:US
Mailing Address - Phone:516-632-4862
Mailing Address - Fax:516-336-2956
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:E-3
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1551
Practice Address - Country:US
Practice Address - Phone:516-632-3640
Practice Address - Fax:516-336-2958
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2015-04-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYF 306701363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner