Provider Demographics
NPI:1093723702
Name:PERRY, MARLENE ANN (PA)
Entity Type:Individual
Prefix:MISS
First Name:MARLENE
Middle Name:ANN
Last Name:PERRY
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 1:60 ABRUYN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-5649
Mailing Address - Country:US
Mailing Address - Phone:845-338-7073
Mailing Address - Fax:
Practice Address - Street 1:4250 ALBANY POST ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:12538
Practice Address - Country:US
Practice Address - Phone:845-229-2602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004962-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant