Provider Demographics
NPI:1316318835
Name:MOOTOO, MARYNA (PA)
Entity type:Individual
Prefix:
First Name:MARYNA
Middle Name:
Last Name:MOOTOO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 OLIVER ST APT 5G
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-6585
Mailing Address - Country:US
Mailing Address - Phone:347-545-7771
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-8958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019123363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0007008OtherAETNAUSHEALTHCARE
NY02998736Medicaid
NY000057OtherBLUE CROSS
IC0023OtherPHYSICIANS HEALTH
000502001OtherAMERICHOICE
71002OtherELDERPLAN
HO4400OtherOXFORD
NY330194Medicare Oscar/Certification