Basic Information
| Provider Information | |||||||||
| NPI: | 1619246071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATLUCK | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | RAGAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ND, FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 30 BROAD ST FL 45 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100042942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125300630 | ||||||||
| FaxNumber: | 2128674353 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 BROAD ST FL 45 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100042942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125300630 | ||||||||
| FaxNumber: | 2128674353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2011 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 805445 | CA | N | Nursing Service Providers | Registered Nurse | 175F00000X | ND-480 | CA | N | Other Service Providers | Naturopath | 363L00000X | 21394 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 337922 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.