Provider Demographics
NPI:1407056435
Name:MICHAEL, MARCIA (NP)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:
Other - Last Name:MICHAEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:6851 JERICHO TPKE
Mailing Address - Street 2:STE 150
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4462
Mailing Address - Country:US
Mailing Address - Phone:646-363-0530
Mailing Address - Fax:
Practice Address - Street 1:14042 184TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11413-3047
Practice Address - Country:US
Practice Address - Phone:718-749-4802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF344853363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner