Basic Information
| Provider Information | |||||||||
| NPI: | 1184646903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RENNA | ||||||||
| OtherFirstName: | MARISA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 430 | ||||||||
| Address2: | EMERGENCY PRACTICE PLAN | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106686491 | ||||||||
| FaxNumber: | 6106176280 | ||||||||
| Practice Location | |||||||||
| Address1: | 56-45 MAIN ST | ||||||||
| Address2: | NEW YORK HOSPITAL MEDICAL CENTER OF QUEEN EMERGENCY DEP | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186701231 | ||||||||
| FaxNumber: | 6106176280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 009575 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.