Provider Demographics
NPI:1043496763
Name:BENETATOS, AGATHAE GRACE (RPAC)
Entity Type:Individual
Prefix:MS
First Name:AGATHAE
Middle Name:GRACE
Last Name:BENETATOS
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 MARYLAND AVE
Mailing Address - Street 2:3D
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-2973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 MARYLAND AVE
Practice Address - Street 2:3D
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-2973
Practice Address - Country:US
Practice Address - Phone:718-816-5601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004994363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical