Provider Demographics
NPI:1104116763
Name:ENG BURGER, MALLORY (MS, CPNP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:ENG BURGER
Suffix:
Gender:F
Credentials:MS, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:10977-8916
Mailing Address - Country:US
Mailing Address - Phone:845-354-9033
Mailing Address - Fax:
Practice Address - Street 1:728 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW SQUARE
Practice Address - State:NY
Practice Address - Zip Code:10977-8916
Practice Address - Country:US
Practice Address - Phone:845-354-9033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR195051363LP0200X, 163W00000X
NY617014163W00000X
NY382293363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid
211876Medicare Oscar/Certification
S118Medicare PIN