Provider Demographics
NPI:1528130895
Name:BERNARDEZ, SHARON (PT)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:BERNARDEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6039 78TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-5307
Mailing Address - Country:US
Mailing Address - Phone:917-476-3188
Mailing Address - Fax:
Practice Address - Street 1:6039 78TH ST
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-5307
Practice Address - Country:US
Practice Address - Phone:917-476-3188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017710174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
03836Medicare ID - Type Unspecified