Healthcare Provider Details

I. General information

NPI: 1619246071
Provider Name (Legal Business Name): ERICA RAGAN MATLUCK ND, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BROAD ST FL 45
NEW YORK NY
10004-2942
US

IV. Provider business mailing address

30 BROAD ST FL 45
NEW YORK NY
10004-2942
US

V. Phone/Fax

Practice location:
  • Phone: 212-530-0630
  • Fax: 212-867-4353
Mailing address:
  • Phone: 212-530-0630
  • Fax: 212-867-4353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number805445
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND-480
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number21394
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number337922
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: