Provider Demographics
NPI:1093877516
Name:GRZESKOWIAK, MARINA (PA)
Entity Type:Individual
Prefix:MS
First Name:MARINA
Middle Name:
Last Name:GRZESKOWIAK
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 1:5800 3RD AVE
Mailing Address - Street 2:MANAGED CARE DEPARTMENT
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3702
Mailing Address - Country:US
Mailing Address - Phone:718-630-7477
Mailing Address - Fax:718-630-7437
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:LMC STROKE CENTER ADMINISTRATION
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2559
Practice Address - Country:US
Practice Address - Phone:718-630-7316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008949363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5F6411Medicare ID - Type Unspecified