Provider Demographics
NPI:1093061772
Name:KOGAN, MARIYA (APRN)
Entity type:Individual
Prefix:
First Name:MARIYA
Middle Name:
Last Name:KOGAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1598
Mailing Address - Street 2:
Mailing Address - City:CAMPTON
Mailing Address - State:NH
Mailing Address - Zip Code:03223-1598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 SAINT JOHNSBURY RD
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:NH
Practice Address - Zip Code:03561-3442
Practice Address - Country:US
Practice Address - Phone:603-444-9565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH073409-23367500000X
NY505545367500000X
FL9281556367500000X
CA4241367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3104728Medicaid
VT1027790Medicaid
NHT400352253OtherNH MEDICARE
VTMK4499338OtherDEA
NHT400352253OtherNH MEDICARE