Provider Demographics
NPI:1972104958
Name:NIETES, JONATHAN DILLERA (MSN, AGPC NP)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DILLERA
Last Name:NIETES
Suffix:
Gender:M
Credentials:MSN, AGPC NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W 59TH ST STE 4F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-8022
Mailing Address - Country:US
Mailing Address - Phone:917-982-6498
Mailing Address - Fax:
Practice Address - Street 1:425 W 59TH ST STE 4F
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-8022
Practice Address - Country:US
Practice Address - Phone:212-241-1272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309611363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health