Basic Information
Provider Information | |||||||||
NPI: | 1992048409 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PISKOZUB | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 68 SOUTH SERVICE ROAD | ||||||||
Address2: | SUITE 350 | ||||||||
City: | MELVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 117473090 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5169453000 | ||||||||
FaxNumber: | 5169453131 | ||||||||
Practice Location | |||||||||
Address1: | 3998 FAIR RIDGE DR | ||||||||
Address2: | SUITE 320 | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220332907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7032959360 | ||||||||
FaxNumber: | 7032959369 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2013 | ||||||||
LastUpdateDate: | 03/13/2015 | ||||||||
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 | 367500000X | R199524 | MD | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 0024171249 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | PENDING | 05 | VA |   | MEDICAID |