Provider Demographics
NPI:1114177441
Name:KOROGODSKY, MARIA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:KOROGODSKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 SOFTWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-6791
Mailing Address - Country:US
Mailing Address - Phone:973-972-5686
Mailing Address - Fax:
Practice Address - Street 1:65 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3001
Practice Address - Country:US
Practice Address - Phone:973-972-5686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00067500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00067500OtherGASTROENTEROLOGY