MEDICARE: TAMOIYA MULLGRAV

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	163W00000X	Registered Nurse	624788	NY

General Provider Information

NPI Number	:	1497074280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMOIYA MULLGRAV

Provider Business Mailing Address
First Line	:	13502 FOCH BLVD
Second Line	:
City	:	SOUTH OZONE PARK
State	:	NY
Zip	:	11420-2228
Country	:	US
Telephone Number	:	718-659-1275
Fax Number	:

Provider Business Practice Location Address
First Line	:	13502 FOCH BLVD
Second Line	:
City	:	SOUTH OZONE PARK
State	:	NY
Zip	:	11420-2228
Country	:	US
Telephone Number	:	718-659-1275
Fax Number	:

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

Provider Enumeration Date	:	05/19/2010
Last Update Date	:	05/19/2010

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