Provider Demographics
NPI:1114766086
Name:FORTUNAT, YVAN (NP)
Entity type:Individual
Prefix:
First Name:YVAN
Middle Name:
Last Name:FORTUNAT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 OCEAN AVE APT 6B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-7428
Mailing Address - Country:US
Mailing Address - Phone:607-624-3251
Mailing Address - Fax:
Practice Address - Street 1:1220 OCEAN AVE APT 6B
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-7428
Practice Address - Country:US
Practice Address - Phone:607-624-3251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311760-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health