Basic Information
| Provider Information | |||||||||
| NPI: | 1780658179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WRIGHT | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 N 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146648000 | ||||||||
| FaxNumber: | 9146648015 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 N 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146648000 | ||||||||
| FaxNumber: | 9146648015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 10/09/2007 | ||||||||
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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 | 363LF0000X | F331921-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 02367559 | 05 | NY | MEDICAID |