Provider Demographics
NPI:1619246071
Name:MATLUCK, ERICA RAGAN (ND, FNP)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:RAGAN
Last Name:MATLUCK
Suffix:
Gender:F
Credentials:ND, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BROAD ST FL 45
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-2942
Mailing Address - Country:US
Mailing Address - Phone:212-530-0630
Mailing Address - Fax:212-867-4353
Practice Address - Street 1:30 BROAD ST FL 45
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-2942
Practice Address - Country:US
Practice Address - Phone:212-530-0630
Practice Address - Fax:212-867-4353
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA805445163W00000X
CAND-480175F00000X
CA21394363L00000X
NY337922363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No175F00000XOther Service ProvidersNaturopath