Basic Information
| Provider Information | |||||||||
| NPI: | 1336265826 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUBIN | ||||||||
| FirstName: | IRIS | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ARIAS | ||||||||
| OtherFirstName: | IRIS | ||||||||
| OtherMiddleName: | C. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6 HEALTHY WAY | ||||||||
| Address2: | |||||||||
| City: | ELLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124285612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456474500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6 HEALTHY WAY | ||||||||
| Address2: | |||||||||
| City: | ELLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124285612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456474500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 378068 | NY | N | Nursing Service Providers | Registered Nurse | 363LF0000X | F331142 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03167993 | 05 | NY | MEDICAID |