Provider Demographics
NPI:1407387251
Name:PUI-CHING MAK, NURSE PRACTITIONER IN GERONTOLOGY, PLLC
Entity Type:Organization
Organization Name:PUI-CHING MAK, NURSE PRACTITIONER IN GERONTOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:MS
Authorized Official - First Name:PUI-CHING
Authorized Official - Middle Name:E
Authorized Official - Last Name:MAK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:917-930-5388
Mailing Address - Street 1:139 CENTRE ST STE 715A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4557
Mailing Address - Country:US
Mailing Address - Phone:917-930-5388
Mailing Address - Fax:
Practice Address - Street 1:139 CENTRE ST STE 715A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4557
Practice Address - Country:US
Practice Address - Phone:917-930-5388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340472261QH0100X, 363LG0600X
NY440039363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03573420Medicaid
NY03573420Medicaid