Provider Demographics
NPI:1427300441
Name:MASTRANDREA, MARC-ELLIOT (LAC)
Entity type:Individual
Prefix:MR
First Name:MARC-ELLIOT
Middle Name:
Last Name:MASTRANDREA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2366 28TH ST
Mailing Address - Street 2:APT 2
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2802
Mailing Address - Country:US
Mailing Address - Phone:917-536-6126
Mailing Address - Fax:
Practice Address - Street 1:2366 28TH ST
Practice Address - Street 2:APT 2
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2802
Practice Address - Country:US
Practice Address - Phone:917-536-6126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000532171100000X
NY4600171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist