Basic Information
| Provider Information | |||||||||
| NPI: | 1184091902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTLYEWSKI | ||||||||
| FirstName: | EDWARD | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 W 168TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123425155 | ||||||||
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| Practice Location | |||||||||
| Address1: | 171 FORT WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123055098 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2015 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F307476-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 26NJ00501000 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | H140070 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.