Basic Information
| Provider Information | |||||||||
| NPI: | 1235303066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTAR | ||||||||
| FirstName: | MYRNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DESVARIEUX | ||||||||
| OtherFirstName: | MYRNA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | ONE PENN PLAZA | ||||||||
| Address2: | 7TH FLOOR, SUITE 725 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101190206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008422478 | ||||||||
| FaxNumber: | 2122166606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PENN PLZ | ||||||||
| Address2: | 7TH FLOOR, SUITE 725 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101190002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008422478 | ||||||||
| FaxNumber: | 2122166606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2008 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F335366 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | F335366 | 01 | NY | NY STATE NP LICENSE | OTHER |