Provider Demographics
NPI:1073133153
Name:MYERS, MARIA JIDRISKA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:JIDRISKA
Last Name:MYERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BUDD AVE
Mailing Address - Street 2:
Mailing Address - City:BUDD LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07828-2404
Mailing Address - Country:US
Mailing Address - Phone:908-917-8361
Mailing Address - Fax:
Practice Address - Street 1:23-00 NJ-208
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:973-200-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00927000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily