Provider Demographics
NPI:1194250456
Name:ADVANCE MEDICAL & WELLNESS
Entity type:Organization
Organization Name:ADVANCE MEDICAL & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHYTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-990-3961
Mailing Address - Street 1:730 RIVERSIDE DR
Mailing Address - Street 2:APT. 4E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-2441
Mailing Address - Country:US
Mailing Address - Phone:917-580-1875
Mailing Address - Fax:
Practice Address - Street 1:730 RIVERSIDE DR
Practice Address - Street 2:APT. 4E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-2441
Practice Address - Country:US
Practice Address - Phone:917-580-1875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7110511363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty