Provider Demographics
NPI:1235464298
Name:STACO, MIRA F (NPP ANP)
Entity Type:Individual
Prefix:MRS
First Name:MIRA
Middle Name:F
Last Name:STACO
Suffix:
Gender:F
Credentials:NPP ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3517
Mailing Address - Country:US
Mailing Address - Phone:516-569-0887
Mailing Address - Fax:516-569-0887
Practice Address - Street 1:819 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3517
Practice Address - Country:US
Practice Address - Phone:516-569-0887
Practice Address - Fax:516-569-0887
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306665363LA2200X
NY401229363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health