Provider Demographics
NPI:1588478085
Name:SACKIE, MOSES
Entity type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:SACKIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-5434
Mailing Address - Country:US
Mailing Address - Phone:347-589-1869
Mailing Address - Fax:
Practice Address - Street 1:777 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3409
Practice Address - Country:US
Practice Address - Phone:718-351-8344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY952743-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse