Provider Demographics
NPI:1659929446
Name:PULTMAN, PENINA MALKA (PA)
Entity Type:Individual
Prefix:MRS
First Name:PENINA
Middle Name:MALKA
Last Name:PULTMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 40TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-1476
Mailing Address - Country:US
Mailing Address - Phone:347-786-1148
Mailing Address - Fax:
Practice Address - Street 1:1020 40TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-1476
Practice Address - Country:US
Practice Address - Phone:347-786-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023981363A00000X
NJ25MP00550400363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant