Provider Demographics
NPI:1780884205
Name:BLAU, MIRIAM S (RN, PNP)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:S
Last Name:BLAU
Suffix:
Gender:F
Credentials:RN, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ISMAY ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5019
Mailing Address - Country:US
Mailing Address - Phone:917-744-1740
Mailing Address - Fax:
Practice Address - Street 1:7 ISMAY ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5019
Practice Address - Country:US
Practice Address - Phone:917-744-1740
Practice Address - Fax:718-815-8122
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY520046-1163W00000X
NY381940363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02460364Medicaid