Provider Demographics
NPI:1124775416
Name:OBRADOVIC, ALEXANDER (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:OBRADOVIC
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 PEACH TREE COMMON
Mailing Address - Street 2:
Mailing Address - City:ST CATHARINES
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L2N0B6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N VILLAGE AVE STE 27
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3712
Practice Address - Country:US
Practice Address - Phone:416-802-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403934363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health