Provider Demographics
NPI:1023716388
Name:PEARSON, MARIAH T
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:T
Last Name:PEARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6080 JERICHO TPKE STE 200
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2808
Mailing Address - Country:US
Mailing Address - Phone:631-864-7770
Mailing Address - Fax:631-864-7773
Practice Address - Street 1:680 JERICHO TURNPIKE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725
Practice Address - Country:US
Practice Address - Phone:631-864-7770
Practice Address - Fax:631-864-7773
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY808657655OtherSTATE ID