Provider Demographics
NPI:1962970624
Name:COUSINS, MARVIN
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:COUSINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 ROCKAWAY PKWY APT 1R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-3485
Mailing Address - Country:US
Mailing Address - Phone:347-570-7665
Mailing Address - Fax:
Practice Address - Street 1:356 ROCKAWAY PKWY APT 1R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3485
Practice Address - Country:US
Practice Address - Phone:347-570-7665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-10
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342858363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily