Provider Demographics
NPI:1003354622
Name:GOLDBERG, REGINA (PA)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SEAVIEW AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305
Mailing Address - Country:US
Mailing Address - Phone:718-667-1777
Mailing Address - Fax:718-667-4380
Practice Address - Street 1:500 SEAVIEW AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3421
Practice Address - Country:US
Practice Address - Phone:718-667-1777
Practice Address - Fax:718-667-4380
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004935-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant