Provider Demographics
NPI:1285158931
Name:PAVLOVSKY, MIRIAM (RN, AGPCNP)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:PAVLOVSKY
Suffix:
Gender:F
Credentials:RN, AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MITCHEL FIELD WAY
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5061
Mailing Address - Country:US
Mailing Address - Phone:347-204-5288
Mailing Address - Fax:
Practice Address - Street 1:1001 MITCHEL FIELD WAY
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5061
Practice Address - Country:US
Practice Address - Phone:347-204-5288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY524614163W00000X, 163WA2000X
NJ26NR17321500363LA2200X
NY308475363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Single Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology