Basic Information
| Provider Information | |||||||||
| NPI: | 1497412787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANGELISTA | ||||||||
| FirstName: | DELIO | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | EVANGELISTA | ||||||||
| OtherFirstName: | DELIO | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3765 SW 90TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330257620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3057632309 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27005 76TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184707000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2021 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 831259 | NY | N | Nursing Service Providers | Registered Nurse | 367500000X | 137202 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 831259 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.