Provider Demographics
NPI:1831759182
Name:ISA, NIDAL
Entity type:Individual
Prefix:
First Name:NIDAL
Middle Name:
Last Name:ISA
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 1:24 SCHOOLHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:WACCABUC
Mailing Address - State:NY
Mailing Address - Zip Code:10597-1112
Mailing Address - Country:US
Mailing Address - Phone:914-354-4975
Mailing Address - Fax:
Practice Address - Street 1:31 RIVERVIEW PL
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-3405
Practice Address - Country:US
Practice Address - Phone:914-354-4975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1234563747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant