Provider Demographics
NPI:1558625160
Name:PAMITTAN, MYRNA (MS)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:PAMITTAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-6549
Mailing Address - Country:US
Mailing Address - Phone:347-963-3978
Mailing Address - Fax:
Practice Address - Street 1:4711 48TH AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-6549
Practice Address - Country:US
Practice Address - Phone:347-963-3978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist