Provider Demographics
NPI:1891355400
Name:MUJTABA, ATHAR (NP)
Entity Type:Individual
Prefix:MR
First Name:ATHAR
Middle Name:
Last Name:MUJTABA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10426 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:718-533-0991
Mailing Address - Fax:833-969-0190
Practice Address - Street 1:10426 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:718-533-0991
Practice Address - Fax:833-969-0190
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344517363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty