Basic Information
| Provider Information | |||||||||
| NPI: | 1558572909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDIBERG | ||||||||
| FirstName: | HOLLIE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 837 | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070390837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003450064 | ||||||||
| FaxNumber: | 9737401350 | ||||||||
| Practice Location | |||||||||
| Address1: | 153 W 11TH ST | ||||||||
| Address2: | ST. VINCENT'S HOSPITAL | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100118305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126047000 | ||||||||
| FaxNumber: | 9737401350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 12/05/2019 | ||||||||
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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 | 363A00000X | 008015-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 008015-1 | 01 | NY | LICENSE | OTHER |