Provider Demographics
NPI:1548911506
Name:BOLOCBOLOC, DANIEL PABAYO
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:PABAYO
Last Name:BOLOCBOLOC
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 1:36 MAINSAIL DR
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3434
Mailing Address - Country:US
Mailing Address - Phone:516-812-7864
Mailing Address - Fax:
Practice Address - Street 1:57-18 WOODSIDE AVE
Practice Address - Street 2:STE 101, 2ND FLOOR
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3415
Practice Address - Country:US
Practice Address - Phone:347-527-2257
Practice Address - Fax:888-720-6963
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348662363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty