Provider Demographics
NPI:1518214220
Name:DORME, JOANNA (PA)
Entity Type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:
Last Name:DORME
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JOANNA
Other - Middle Name:
Other - Last Name:RECIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:355 BARD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1664
Mailing Address - Country:US
Mailing Address - Phone:917-808-9650
Mailing Address - Fax:
Practice Address - Street 1:355 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1664
Practice Address - Country:US
Practice Address - Phone:718-818-2054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MR2695320OtherDEA