Provider Demographics
NPI:1508893157
Name:PEROG, CHERYL J (PA-C, MHS)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:J
Last Name:PEROG
Suffix:
Gender:F
Credentials:PA-C, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 LEA DR
Mailing Address - Street 2:
Mailing Address - City:DELANSON
Mailing Address - State:NY
Mailing Address - Zip Code:12053-3551
Mailing Address - Country:US
Mailing Address - Phone:518-875-6192
Mailing Address - Fax:518-875-9037
Practice Address - Street 1:ST. PETER'S HOSPITOAL OCCUPATIONAL HEALTH
Practice Address - Street 2:310 SOUTH MANNING BOULEVARD
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12053
Practice Address - Country:US
Practice Address - Phone:518-525-2363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003521363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003521OtherLICENSE