Provider Demographics
NPI:1164703872
Name:TACZANOWSKI BERSIN, EVA M (PA)
Entity Type:Individual
Prefix:MRS
First Name:EVA
Middle Name:M
Last Name:TACZANOWSKI BERSIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:2A JOEL PL
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-3442
Mailing Address - Country:US
Mailing Address - Phone:516-944-4009
Mailing Address - Fax:516-944-4009
Practice Address - Street 1:833 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5315
Practice Address - Country:US
Practice Address - Phone:516-498-8400
Practice Address - Fax:516-498-8404
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY005719-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical