Provider Demographics
NPI:1275053142
Name:MAMUYAC, LORA LUMUBOS (AGPCNP)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:LUMUBOS
Last Name:MAMUYAC
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-4208
Mailing Address - Country:US
Mailing Address - Phone:631-902-8439
Mailing Address - Fax:
Practice Address - Street 1:18 1ST AVE
Practice Address - Street 2:
Practice Address - City:HOLTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11742-4208
Practice Address - Country:US
Practice Address - Phone:631-902-8439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307956-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health