Provider Demographics
NPI:1669655502
Name:QUEZADA, XIOMARA D (PA)
Entity Type:Individual
Prefix:
First Name:XIOMARA
Middle Name:D
Last Name:QUEZADA
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 1:158 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLORIDA
Mailing Address - State:NY
Mailing Address - Zip Code:10921-1133
Mailing Address - Country:US
Mailing Address - Phone:845-651-1412
Mailing Address - Fax:845-651-1512
Practice Address - Street 1:1200 STATE ROUTE 208
Practice Address - Street 2:STE 13
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4648
Practice Address - Country:US
Practice Address - Phone:845-783-6266
Practice Address - Fax:845-783-9570
Is Sole Proprietor?:No
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009534-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant