Basic Information
| Provider Information | |||||||||
| NPI: | 1205076411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PESTRAK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3579 WYANET ST | ||||||||
| Address2: | |||||||||
| City: | SEAFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117833011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185268400 | ||||||||
| FaxNumber: | 7185233063 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HEMPSTEAD AVE STE 154H | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE CENTRE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115704033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167377018 | ||||||||
| FaxNumber: | 5163313175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2009 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | F401181-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.