Provider Demographics
NPI:1154865269
Name:BURGOS, MARVIN ALEXANDER (RN)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:ALEXANDER
Last Name:BURGOS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 PARKER ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4978
Mailing Address - Country:US
Mailing Address - Phone:914-426-7952
Mailing Address - Fax:
Practice Address - Street 1:1654 PARKER ST APT 1C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4978
Practice Address - Country:US
Practice Address - Phone:914-426-7952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246ZC0007X246ZC0007X
NY909992163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYFV47428WOtherFIDELISCARE
NYW284879900OtherAETNA