Provider Demographics
NPI:1558469601
Name:BHUIYAN, MARIE ROSE BURGONIO
Entity Type:Individual
Prefix:
First Name:MARIE ROSE
Middle Name:BURGONIO
Last Name:BHUIYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE ROSE
Other - Middle Name:BURGONIO
Other - Last Name:DOMINGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN,BC, PMHNP
Mailing Address - Street 1:301 COVERT AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-5436
Mailing Address - Country:US
Mailing Address - Phone:516-352-3771
Mailing Address - Fax:
Practice Address - Street 1:9020 191ST ST
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2518
Practice Address - Country:US
Practice Address - Phone:718-721-3523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401016-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02827085Medicaid
NY02827085Medicaid