Healthcare Provider Details

I. General information

NPI: 1225789787
Provider Name (Legal Business Name): MARISOL MARIE VENTURA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2022
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 E 76TH ST FL 2
NEW YORK NY
10021-2822
US

IV. Provider business mailing address

186 E 76TH ST FL 2
NEW YORK NY
10021-2822
US

V. Phone/Fax

Practice location:
  • Phone: 212-434-2323
  • Fax: 212-434-6885
Mailing address:
  • Phone: 212-434-2323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number03189401
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: