1942492897 NPI number — MARY ANNE MIRANDA NP-C

Table of content: MARY ANNE MIRANDA NP-C (NPI 1942492897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942492897 NPI number — MARY ANNE MIRANDA NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIRANDA
Provider First Name:
MARY ANNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942492897
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRAL ISLIP
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11722-4111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-232-1572
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
931 HALLOCK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT JEFFERSON STATION
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11776-1228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-331-7200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  F304650 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)