Provider Demographics
NPI:1083330823
Name:BARANOWSKI, JOHN EDWIN (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWIN
Last Name:BARANOWSKI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3833
Mailing Address - Country:US
Mailing Address - Phone:207-812-8616
Mailing Address - Fax:
Practice Address - Street 1:717 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3833
Practice Address - Country:US
Practice Address - Phone:207-812-8616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028892-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant