Provider Demographics
NPI:1659460236
Name:ENG, IRENE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:ENG
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 1:25 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-4122
Mailing Address - Country:US
Mailing Address - Phone:845-343-4141
Mailing Address - Fax:845-343-1535
Practice Address - Street 1:25 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-4122
Practice Address - Country:US
Practice Address - Phone:845-343-4141
Practice Address - Fax:845-343-1535
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002456OtherNYS LICENSE
NY8194L35561-2-3Medicare PIN