MEDICARE: MARY SIRAGUSA RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WS0200X	School Registered Nurse	22317601	NY

General Provider Information

NPI Number	:	1063787869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY SIRAGUSA RN

Provider Business Mailing Address
First Line	:	4108 VICTORY BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6743
Country	:	US
Telephone Number	:	718-698-1530
Fax Number	:	718-982-9798

Provider Business Practice Location Address
First Line	:	4108 VICTORY BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6743
Country	:	US
Telephone Number	:	718-698-1530
Fax Number	:	718-982-9798

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2012
Last Update Date	:	03/13/2012

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