Provider Demographics
NPI:1427485614
Name:HALTER, JONATHAN E (RN)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:E
Last Name:HALTER
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 1:2558 44TH ST
Mailing Address - Street 2:APT# 1
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-2004
Mailing Address - Country:US
Mailing Address - Phone:718-224-0566
Mailing Address - Fax:718-224-7544
Practice Address - Street 1:5820 LITTLE NECK PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-2530
Practice Address - Country:US
Practice Address - Phone:718-224-0566
Practice Address - Fax:718-224-7544
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY670905163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY670905OtherLICENSE
NY0138263Medicaid