Provider Demographics
NPI:1629463898
Name:MERMELSTEIN, MARCUS SAMUEL
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:SAMUEL
Last Name:MERMELSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4609 11TH ST APT 5E
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5367
Mailing Address - Country:US
Mailing Address - Phone:510-301-4314
Mailing Address - Fax:
Practice Address - Street 1:4609 11TH ST APT 5E
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5367
Practice Address - Country:US
Practice Address - Phone:510-301-4314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical