Basic Information
Provider Information
NPI: 1003153230
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MAUL
FirstName: CHARAKA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 69 TRINITY PL
Address2: APT 205
City: ALBANY
State: NY
PostalCode: 122021840
CountryCode: US
TelephoneNumber: 7187300384
FaxNumber:  
Practice Location
Address1: 69 TRINITY PL
Address2: APT 205
City: ALBANY
State: NY
PostalCode: 122021840
CountryCode: US
TelephoneNumber: 7187300384
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/08/2013
LastUpdateDate: 01/08/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
164W00000X287569NYY Nursing Service ProvidersLicensed Practical Nurse 

No ID Information.


Home