Provider Demographics
NPI:1588798904
Name:AMMIRATI, MARY (RPA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:AMMIRATI
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:DE LOS REYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 BROOKDALE PLZ
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-3139
Mailing Address - Country:US
Mailing Address - Phone:718-240-5978
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKDALE PLZ
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3139
Practice Address - Country:US
Practice Address - Phone:718-240-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2011-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010488363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant