Basic Information
| Provider Information | |||||||||
| NPI: | 1043491046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANGI-POLLACEK | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | CATHERINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GANGI | ||||||||
| OtherFirstName: | DENISE | ||||||||
| OtherMiddleName: | CATHERINE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
| FaxNumber: | 5186494094 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 BURDETT AVE | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121802466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182713300 | ||||||||
| FaxNumber: | 5182713440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 012196 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 03155626 | 05 | NY | MEDICAID |