Basic Information
| Provider Information | |||||||||
| NPI: | 1407899339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARE | ||||||||
| FirstName: | PRISCILLA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 441 9TH AVE | ||||||||
| Address2: | CREDENTIALING 3RD FL | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100011623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802894 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 4337 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100332411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125686300 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 12/09/2015 | ||||||||
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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 | 208000000X | 136581 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00896135 | 05 | NY | MEDICAID |