Provider Demographics
NPI:1558572909
Name:MANDIBERG, HOLLIE (PA)
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:
Last Name:MANDIBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 837
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-0837
Mailing Address - Country:US
Mailing Address - Phone:800-345-0064
Mailing Address - Fax:973-740-1350
Practice Address - Street 1:153 W 11TH ST
Practice Address - Street 2:ST. VINCENT'S HOSPITAL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8305
Practice Address - Country:US
Practice Address - Phone:212-604-7000
Practice Address - Fax:973-740-1350
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008015-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY008015-1OtherLICENSE