Provider Demographics
NPI:1588819981
Name:GOLDBURD, MIRIAM ZLATA (PA)
Entity Type:Individual
Prefix:MISS
First Name:MIRIAM
Middle Name:ZLATA
Last Name:GOLDBURD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:ZLATA
Other - Last Name:BERGSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1540 EAST 36TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234
Mailing Address - Country:US
Mailing Address - Phone:718-614-5578
Mailing Address - Fax:718-972-1661
Practice Address - Street 1:4809 14TH AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219
Practice Address - Country:US
Practice Address - Phone:718-972-7432
Practice Address - Fax:718-972-1661
Is Sole Proprietor?:No
Enumeration Date:2008-11-26
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012888363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY012888OtherLICENSE NUMBER