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General NPI Number Information
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NPI Number | 1750845137
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Entity Type | Organization
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Legal Business Name | MIRIAM GORDON PEDIATRIC NP PC
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Dates
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Enumeration Date | 01/30/2019
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Last Update Date | 01/30/2019
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Provider Practice Location Address
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Address Line | 7 ISMAY STREET
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City | STATEN ISLAND
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State | NY
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Zip | 10314
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Country | US
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Telephone | 718-815-1000
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Fax | 718-815-1000
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Provider Business Mailing Address
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Address Line | 7 ISMAY STREET
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City | STATEN ISLAND
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State | NY
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Zip | 10314
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Country | US
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Telephone | 718-815-1000
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Fax | 718-815-8122
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Authorized Official
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Title or Position | CEO
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Name | MIRIAM BLAU
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Credential | NP
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Telephone | 718-815-8122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number |
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License Number State |
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