Basic Information
Provider Information | |||||||||
NPI: | 1851370308 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARTKA | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DICKER | ||||||||
OtherFirstName: | MELISSA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 19 BRADHURST AVE STE 3100N | ||||||||
Address2: |   | ||||||||
City: | HAWTHORNE | ||||||||
State: | NY | ||||||||
PostalCode: | 105322140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9149099018 | ||||||||
FaxNumber: | 9149099028 | ||||||||
Practice Location | |||||||||
Address1: | 396 BROADWAY | ||||||||
Address2: |   | ||||||||
City: | KINGSTON | ||||||||
State: | NY | ||||||||
PostalCode: | 124014626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8453313131 | ||||||||
FaxNumber: | 8453312530 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/12/2006 | ||||||||
LastUpdateDate: | 01/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 340666 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.