Provider Demographics
NPI:1831806520
Name:MANNAN, MONIKA
Entity type:Individual
Prefix:
First Name:MONIKA
Middle Name:
Last Name:MANNAN
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 1:4030 73RD ST APT B12
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3071
Mailing Address - Country:US
Mailing Address - Phone:917-340-8594
Mailing Address - Fax:
Practice Address - Street 1:1027 46TH AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5245
Practice Address - Country:US
Practice Address - Phone:212-385-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant