Provider Demographics
NPI:1497087654
Name:DEGEORGE, MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:
Last Name:DEGEORGE
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 1:113 KISSAM LANE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD LANDING
Mailing Address - State:NY
Mailing Address - Zip Code:11547-0127
Mailing Address - Country:US
Mailing Address - Phone:516-671-4640
Mailing Address - Fax:
Practice Address - Street 1:2601 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7745
Practice Address - Country:US
Practice Address - Phone:718-616-4387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003358363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant