Provider Demographics
NPI:1053713164
Name:DERVISHI, PRANVERA (PA)
Entity type:Individual
Prefix:
First Name:PRANVERA
Middle Name:
Last Name:DERVISHI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 ASTOR AVE
Mailing Address - Street 2:PVH 2ND FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5832
Mailing Address - Country:US
Mailing Address - Phone:646-703-2048
Mailing Address - Fax:
Practice Address - Street 1:1334 ASTOR AVE
Practice Address - Street 2:PVH 2ND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5832
Practice Address - Country:US
Practice Address - Phone:646-703-2048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018011363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical