Provider Demographics
NPI:1235303066
Name:MATTAR, MYRNA (NP)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:MATTAR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MYRNA
Other - Middle Name:
Other - Last Name:DESVARIEUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:ONE PENN PLAZA
Mailing Address - Street 2:7TH FLOOR, SUITE 725
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10119-0206
Mailing Address - Country:US
Mailing Address - Phone:800-842-2478
Mailing Address - Fax:212-216-6606
Practice Address - Street 1:1 PENN PLZ
Practice Address - Street 2:7TH FLOOR, SUITE 725
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10119-0002
Practice Address - Country:US
Practice Address - Phone:800-842-2478
Practice Address - Fax:212-216-6606
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335366363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF335366OtherNY STATE NP LICENSE