Basic Information
| Provider Information | |||||||||
| NPI: | 1851578520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'MALLEY | ||||||||
| FirstName: | MAURA | ||||||||
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| NamePrefix: | MS. | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2791 RICHMOND AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103145882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188166440 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1050 CLOVE ROAD | ||||||||
| Address2: | STATEN ISLAND PHYSICIAN PRACTICE | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103045509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188166440 | ||||||||
| FaxNumber: | 7188163749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 07/18/2013 | ||||||||
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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 | 363LA2200X | F304408-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 02990370 | 05 | NY | MEDICAID |