Provider Demographics
NPI:1932431780
Name:IYASERE, EGBE (RN)
Entity Type:Individual
Prefix:
First Name:EGBE
Middle Name:
Last Name:IYASERE
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 1:648 CONCORD AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-3125
Mailing Address - Country:US
Mailing Address - Phone:718-671-2100
Mailing Address - Fax:
Practice Address - Street 1:648 CONCORD AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3125
Practice Address - Country:US
Practice Address - Phone:718-671-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY622148163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse