| NPI |
1861804346 |
The 10-position telephone number of the authorized official. |
| Entity Type Code |
1 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider Last Name Legal Name |
MESA |
|
| Provider First Name |
MAIRA |
|
| Provider First Line Business Practice Location Address |
5122 71ST ST |
|
| Provider Business Practice Location Address City Name |
WOODSIDE |
|
| Provider Business Practice Location Address State Name |
NY |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider Business Practice Location Address Postal Code |
113777618 |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
|
| Provider Business Practice Location Address Telephone Number |
3477926912 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Provider Enumeration Date |
6/2/2014 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Last Update Date |
6/2/2014 |
|
| Provider Gender Code |
F |
The code designating the provider’s gender if the provider is a person. |
| Healthcare Provider Taxonomy Code 1 |
390200000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |