Provider Demographics
NPI:1275604654
Name:SEGARRA, IVONNE (PA)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:
Last Name:SEGARRA
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 1:8 SHERRI LN
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-1308
Mailing Address - Country:US
Mailing Address - Phone:718-920-2961
Mailing Address - Fax:
Practice Address - Street 1:MMC - DEPT. OF MEDICINE
Practice Address - Street 2:111 EAST 210TH STREET
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-2961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant