Basic Information
| Provider Information | |||||||||
| NPI: | 1215017397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRONES | ||||||||
| FirstName: | MARCO | ||||||||
| MiddleName: | ANTONIO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 972 BRUSH HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168765555 | ||||||||
| FaxNumber: | 5168761246 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 OLD COUNTRY RD | ||||||||
| Address2: | |||||||||
| City: | PLAINVIEW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 118034914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167193000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 06/25/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 008261-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 00246075 | 05 | NY | MEDICAID |