Provider Demographics
NPI:1386650489
Name:PERAZZO, MARINA (PA)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:PERAZZO
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:PO BOX 32870
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150
Mailing Address - Country:US
Mailing Address - Phone:212-523-6720
Mailing Address - Fax:
Practice Address - Street 1:1360 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305
Practice Address - Country:US
Practice Address - Phone:718-667-3577
Practice Address - Fax:718-351-7151
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0060091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4F881Medicare ID - Type Unspecified
P39870Medicare UPIN