Provider Demographics
NPI:1720578222
Name:MACASAET, GRACE CHRISTIAN RUBIO
Entity Type:Individual
Prefix:
First Name:GRACE CHRISTIAN
Middle Name:RUBIO
Last Name:MACASAET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRACE CHRISTIAN
Other - Middle Name:MACASAET
Other - Last Name:BICOL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5346 67TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1714
Mailing Address - Country:US
Mailing Address - Phone:347-556-9152
Mailing Address - Fax:
Practice Address - Street 1:5346 67TH ST FL 1
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-1714
Practice Address - Country:US
Practice Address - Phone:347-556-9152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY741790163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid