Provider Demographics
NPI:1184646903
Name:RODRIGUEZ, MARISA A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:A
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MARISA
Other - Middle Name:A
Other - Last Name:RENNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:EMERGENCY PRACTICE PLAN
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11352
Mailing Address - Country:US
Mailing Address - Phone:610-668-6491
Mailing Address - Fax:610-617-6280
Practice Address - Street 1:56-45 MAIN ST
Practice Address - Street 2:NEW YORK HOSPITAL MEDICAL CENTER OF QUEEN EMERGENCY DEP
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-670-1231
Practice Address - Fax:610-617-6280
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q17964Medicare UPIN
NY6383WVMedicare ID - Type Unspecified