Provider Demographics
NPI:1194931170
Name:ANDERSON, RUSIAN ELOISE (FNP FAMILY NURSE PRA)
Entity type:Individual
Prefix:MRS
First Name:RUSIAN
Middle Name:ELOISE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP FAMILY NURSE PRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 1ST AVE
Mailing Address - Street 2:METROPOLITAN HOSPITAL CENTER
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-7404
Mailing Address - Country:US
Mailing Address - Phone:646-672-3558
Mailing Address - Fax:646-672-3560
Practice Address - Street 1:1901 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-7404
Practice Address - Country:US
Practice Address - Phone:646-672-3558
Practice Address - Fax:646-672-3560
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333314363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02223792Medicaid
NYP45276Medicare UPIN
NY02223792Medicaid