Provider Demographics
NPI:1376869990
Name:GARCIA, PHYLLIS MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MARIE
Last Name:GARCIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:MARIE
Other - Last Name:VITALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2545 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-6907
Mailing Address - Country:US
Mailing Address - Phone:347-538-3413
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03766525Medicaid