Provider Demographics
NPI:1780570812
Name:RYAN, MARINA (NP)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:NP
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Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 LOUIS KOSSUTH AVE
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-1511
Mailing Address - Country:US
Mailing Address - Phone:631-766-1124
Mailing Address - Fax:
Practice Address - Street 1:1625 LOUIS KOSSUTH AVE
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1511
Practice Address - Country:US
Practice Address - Phone:631-766-1124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF406930-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health