Basic Information
| Provider Information | |||||||||
| NPI: | 1851704910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORALES | ||||||||
| FirstName: | JESUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 LAGUARDIA AVE | ||||||||
| Address2: | APARTMENT 3E | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103145458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188202109 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2795 RICHMOND AVE | ||||||||
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| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103145866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187619800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2014 | ||||||||
| LastUpdateDate: | 06/06/2014 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.