Provider Demographics
NPI:1639689235
Name:ECONOMOS, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ECONOMOS
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 1:9201 SHORE RD APT A703
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-8609
Mailing Address - Country:US
Mailing Address - Phone:718-736-4765
Mailing Address - Fax:
Practice Address - Street 1:14916 80TH ST
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-1108
Practice Address - Country:US
Practice Address - Phone:718-845-4844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant