Provider Demographics
NPI:1699539007
Name:MARYASIS, ALLEN (FNP-C)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:MARYASIS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 BROKEN SOUND PKWY NW APT 319
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-3665
Mailing Address - Country:US
Mailing Address - Phone:917-968-3162
Mailing Address - Fax:
Practice Address - Street 1:844 BROKEN SOUND PKWY NW APT 319
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-3665
Practice Address - Country:US
Practice Address - Phone:917-968-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11030948363L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner