Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 199938 | LA |
N | 111NI0900X | Internist | 199938 | LA |
N | 207R00000X | Internist | 32334 | SC |
N | 111NI0900X | Internist | 32334 | SC |
Y | 207RC0200X | Critical Care Medicine | 32334 | SC |
N | 207RP1001X | Pulmonary Disease | 32334 | SC |
NPI | 1073536074 |
---|---|
Provider Name | Sebastine I Elendu |
First Address | Bayside, NY 11360-1121 |
Second Address | Cheyenne, WY 82001-3176 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 20/05/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02053740 | (05) | MS |
1076350 | (05) | LA |
GP3912 | MEDICAID GROUP (01) | SC |
GP4306 | MEDICAID GROUP (01) | SC |
I21520 | (02) | |
NC1134 | (05) | SC |