Basic Information
| Provider Information | |||||||||
| NPI: | 1275668055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUSTO | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUNN | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | MARY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1113 RHINELANDER AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104611309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187922123 | ||||||||
| FaxNumber: | 7188280145 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PENN PLZ FL 8 | ||||||||
| Address2: | OPTUM | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101190899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3472190784 | ||||||||
| FaxNumber: | 2122166606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | F331529 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 98V361 | 01 | NY | MEDICARE ID | OTHER | 1917624 | 05 | NY | MEDICAID |