Provider Demographics
NPI:1164856910
Name:ORTIZ, MADELINE (PA-C)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:ORTIZ
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 1:124 SMITH ST APT 1E
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-4466
Mailing Address - Country:US
Mailing Address - Phone:516-497-3746
Mailing Address - Fax:
Practice Address - Street 1:521 W 181ST ST
Practice Address - Street 2:FREEPORT
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-5102
Practice Address - Country:US
Practice Address - Phone:347-756-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016507-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical