Provider Demographics
NPI:1770965436
Name:MAYFIELD, MOSHE A (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MR
First Name:MOSHE
Middle Name:A
Last Name:MAYFIELD
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 CRESCENT ST
Mailing Address - Street 2:2B
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-4316
Mailing Address - Country:US
Mailing Address - Phone:347-724-1180
Mailing Address - Fax:
Practice Address - Street 1:211 E 79TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0819
Practice Address - Country:US
Practice Address - Phone:212-879-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2019-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY695125163W00000X
NYF309119363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty