Basic Information
| Provider Information | |||||||||
| NPI: | 1215273149 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIBURCIO | ||||||||
| FirstName: | MELIE | ||||||||
| MiddleName: | SIMON | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27036 | ||||||||
| Address2: | NEW YORK | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100877036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123423892 | ||||||||
| FaxNumber: | 2123425262 | ||||||||
| Practice Location | |||||||||
| Address1: | 177 FORT WASHINGTON AVE | ||||||||
| Address2: | MHB 7-435 GN | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123056003 | ||||||||
| FaxNumber: | 2123050907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2012 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 7607314 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | F337011-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3543304 | 05 | NY | MEDICAID |