Provider Demographics
NPI:1518112192
Name:GEOGHEGAN, MARY B (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:GEOGHEGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 BROADWAY
Mailing Address - Street 2:VNSNY CHOICE 21ST FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-3701
Mailing Address - Country:US
Mailing Address - Phone:212-260-9180
Mailing Address - Fax:212-714-2982
Practice Address - Street 1:1250 BROADWAY
Practice Address - Street 2:VNSNY CHOICE 21ST FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001
Practice Address - Country:US
Practice Address - Phone:212-609-1800
Practice Address - Fax:212-714-2982
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340705363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology