Provider Demographics
NPI:1700377934
Name:MATHEW, JISHA MERIN (MS, FNP-BC)
Entity Type:Individual
Prefix:
First Name:JISHA
Middle Name:MERIN
Last Name:MATHEW
Suffix:
Gender:F
Credentials:MS, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1468 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6508
Mailing Address - Country:US
Mailing Address - Phone:212-241-6639
Mailing Address - Fax:
Practice Address - Street 1:1835 OLIVER AVE
Practice Address - Street 2:APT 4
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580
Practice Address - Country:US
Practice Address - Phone:347-972-7207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342567363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2018000509OtherANCC FNPBC