Healthcare Provider Details

I. General information

NPI: 1992768337
Provider Name (Legal Business Name): MARIA TEREZA SAMSON LOPEZ-CANTOR ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUSTAVE L.LEVY PLACE BOX 3000
NEW YORK NY
10029-6574
US

IV. Provider business mailing address

17 EAST 102ND STREET
NEW YORK NY
10029-6574
US

V. Phone/Fax

Practice location:
  • Phone: 212-987-3100
  • Fax: 212-731-5210
Mailing address:
  • Phone: 212-659-8551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number30-303793
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF303793
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: