Provider Demographics
NPI:1679934483
Name:MUSTAFA, RANYA M
Entity Type:Individual
Prefix:MRS
First Name:RANYA
Middle Name:M
Last Name:MUSTAFA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RANYA
Other - Middle Name:I
Other - Last Name:MADHOUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:192 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1051
Mailing Address - Country:US
Mailing Address - Phone:516-707-9991
Mailing Address - Fax:
Practice Address - Street 1:3O PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1902
Practice Address - Country:US
Practice Address - Phone:551-996-3192
Practice Address - Fax:551-996-4239
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019570363A00000X
NJ25MP00398700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00398700OtherSTATE LICENSE