Basic Information
| Provider Information | |||||||||
| NPI: | 1861948150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONROE | ||||||||
| FirstName: | RACQUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RYAN | ||||||||
| OtherFirstName: | RACQUEL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5010 STATE HIGHWAY 30 STE 205 | ||||||||
| Address2: | |||||||||
| City: | AMSTERDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120107532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188422663 | ||||||||
| FaxNumber: | 5188424861 | ||||||||
| Practice Location | |||||||||
| Address1: | 434 S KINGSBORO AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120953822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187734242 | ||||||||
| FaxNumber: | 5187734246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2016 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F340964 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 340964 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 02049750 | 05 | NY | MEDICAID |