Provider Demographics
NPI:1326409699
Name:RUCANDO, MIRA
Entity Type:Individual
Prefix:MS
First Name:MIRA
Middle Name:
Last Name:RUCANDO
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 1:14414 25TH DR
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-1323
Mailing Address - Country:US
Mailing Address - Phone:516-508-2423
Mailing Address - Fax:
Practice Address - Street 1:14414 25TH DR
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-1323
Practice Address - Country:US
Practice Address - Phone:516-508-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY38 382566363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics