Healthcare Provider Details

I. General information

NPI: 1558818799
Provider Name (Legal Business Name): MARK TRISTAN MARIANO DEGUZMAN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3144 3RD AVE
BRONX NY
10451-4629
US

IV. Provider business mailing address

3144 3RD AVE
BRONX NY
10451-4629
US

V. Phone/Fax

Practice location:
  • Phone: 212-271-7200
  • Fax:
Mailing address:
  • Phone: 212-271-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number691581
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number341549
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: