Provider Demographics
NPI:1497219141
Name:PANZA, EILEEN ROSE
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:ROSE
Last Name:PANZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2981
Mailing Address - Country:US
Mailing Address - Phone:631-549-5700
Mailing Address - Fax:
Practice Address - Street 1:175 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2981
Practice Address - Country:US
Practice Address - Phone:631-549-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant