Provider Demographics
NPI:1811960420
Name:MIRAVITE, JOAN (NP)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:MIRAVITE
Suffix:
Gender:F
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:PO BOX 95000-2445
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2445
Mailing Address - Country:US
Mailing Address - Phone:212-844-6134
Mailing Address - Fax:212-844-8461
Practice Address - Street 1:10 UNION SQ E
Practice Address - Street 2:SUITE 5H
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:212-844-6134
Practice Address - Fax:212-844-8461
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333254363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2 E6521OtherEMPIRE BCBS
NY02266806Medicaid
NY61369Medicare UPIN
NY02266806Medicaid