Provider Demographics
NPI:1306281977
Name:MATAYEVA, MIRA (MS)
Entity type:Individual
Prefix:MRS
First Name:MIRA
Middle Name:
Last Name:MATAYEVA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147-46 75 AVE APT 3 D
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367
Mailing Address - Country:US
Mailing Address - Phone:347-523-3428
Mailing Address - Fax:
Practice Address - Street 1:147-46 75 AVE APT 3 D
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367
Practice Address - Country:US
Practice Address - Phone:347-523-3428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2323606174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist