Provider Demographics
NPI:1578891933
Name:INSIGNARES, GUSTAVO R (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:R
Last Name:INSIGNARES
Suffix:
Gender:M
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 1:725 RIVERSIDE DR
Mailing Address - Street 2:6E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-2450
Mailing Address - Country:US
Mailing Address - Phone:631-944-2495
Mailing Address - Fax:
Practice Address - Street 1:725 RIVERSIDE DR
Practice Address - Street 2:6E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-2450
Practice Address - Country:US
Practice Address - Phone:631-944-2495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003980-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant