Provider Demographics
NPI:1255889978
Name:SHACK, DAVID (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SHACK
Suffix:
Gender:M
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MAIDEN LN
Mailing Address - Street 2:STE 1206
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-4810
Mailing Address - Country:US
Mailing Address - Phone:212-995-6495
Mailing Address - Fax:212-379-6486
Practice Address - Street 1:75 MAIDEN LN
Practice Address - Street 2:STE 1206
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-4810
Practice Address - Country:US
Practice Address - Phone:212-995-6495
Practice Address - Fax:212-379-6486
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307993363LA2200X
FLRN9326000163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health