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General NPI Number Information
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NPI Number | 1710247192
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Entity Type | Individual
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Provider Name | MIRIAM TAVAKOLY
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Gender | Female
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Dates
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Enumeration Date | 05/20/2012
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Last Update Date | 05/20/2012
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Provider Practice Location Address
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Address Line | 1664 E 14TH ST SUITE 101
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City | BROOKLYN
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State | NY
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Zip | 11229-1155
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Country | US
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Telephone | 718-998-2350
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 650067
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City | FRESH MEADOWS
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State | NY
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Zip | 11365-0067
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Country | US
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Telephone | 917-605-7453
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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