Basic Information
| Provider Information | |||||||||
| NPI: | 1962700401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TROAST | ||||||||
| FirstName: | MARYKE | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 HATFIELD LN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452942733 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 HATFIELD LN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452942733 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2011 | ||||||||
| LastUpdateDate: | 11/19/2014 | ||||||||
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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 | 163W00000X | 563529-1 | NY | N | Nursing Service Providers | Registered Nurse | 363LP0200X | F381773-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02734509 | 05 | NY | MEDICAID |