Basic Information
| Provider Information | |||||||||
| NPI: | 1780884205 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAU | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | R.N., P.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 ISMAY ST | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103145019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9177441740 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7 ISMAY ST | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103145019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9177441740 | ||||||||
| FaxNumber: | 7188158122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 520046-1 | NY | N | Nursing Service Providers | Registered Nurse | 363LP0200X | 381940 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02460364 | 05 | NY | MEDICAID |