Provider Demographics
NPI:1700520244
Name:DESTINO, MAX
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:DESTINO
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 1:1333 ROSELLE AVE
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14305-1643
Mailing Address - Country:US
Mailing Address - Phone:716-940-8046
Mailing Address - Fax:
Practice Address - Street 1:1333 ROSELLE AVE
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14305-1643
Practice Address - Country:US
Practice Address - Phone:716-940-8046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY804041163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse