Basic Information
Provider Information | |||||||||
NPI: | 1609273481 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANNINO | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | EMILIO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 WATER ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100410010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6466802888 | ||||||||
FaxNumber: | 5165425556 | ||||||||
Practice Location | |||||||||
Address1: | 4771 HYLAN BLVD | ||||||||
Address2: |   | ||||||||
City: | STATEN ISLAND | ||||||||
State: | NY | ||||||||
PostalCode: | 103126315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189488200 | ||||||||
FaxNumber: | 7184202718 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2014 | ||||||||
LastUpdateDate: | 10/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 26NJ00535800 | NJ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 339326 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.