Healthcare Provider Details

I. General information

NPI: 1629240692
Provider Name (Legal Business Name): ROBERT JAMES MAZAROSKI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2008
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 FRANKLIN AVE
GARDEN CITY NY
11530-2913
US

IV. Provider business mailing address

999 FRANKLIN AVE
GARDEN CITY NY
11530-2913
US

V. Phone/Fax

Practice location:
  • Phone: 516-742-3404
  • Fax: 516-629-3857
Mailing address:
  • Phone: 516-742-3404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number009302
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: