MEDICARE: MS. KATHERINE MARY MAR PNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	F380517-1	NY

General Provider Information

NPI Number	:	1265596142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHERINE MARY MAR PNP

Provider Business Mailing Address
First Line	:	231 W 21ST ST APT 4E
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10011-3118
Country	:	US
Telephone Number	:	212-255-9263
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 JUMEL PL
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10032-4316
Country	:	US
Telephone Number	:	212-923-1495
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	07/08/2007

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