Basic Information
| Provider Information | |||||||||
| NPI: | 1619495199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUCK | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 W 109TH ST APT 4B | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100252226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 19175171081 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100191147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125234000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2017 | ||||||||
| LastUpdateDate: | 09/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 659480-1 | NY | Y | Nursing Service Providers | Registered Nurse |
No ID Information.