MEDICARE: MS. RUBY EZRA A-GNP

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	569398-1	NY
2	363LA2200X	Adult Health Nurse Practitioner	F308975-1	NY

General Provider Information

NPI Number	:	1699088898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RUBY EZRA A-GNP

Provider Business Mailing Address
First Line	:	163 STUYVESANT DR
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-4251
Country	:	US
Telephone Number	:	347-596-6026
Fax Number	:

Provider Business Practice Location Address
First Line	:	163 STUYVESANT DR
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-4251
Country	:	US
Telephone Number	:	631-342-7514
Fax Number	:

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

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	07/02/2021

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