Provider Demographics
NPI:1881555712
Name:MIRONOVA, MARINA (NP)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:MIRONOVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 TIMBER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-6124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:292 TIMBER RIDGE DR
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-6124
Practice Address - Country:US
Practice Address - Phone:347-603-5647
Practice Address - Fax:347-695-1117
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-20
Last Update Date:2025-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311058363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner