Provider Demographics
NPI:1699840843
Name:PITAMBER, MARLENE MALETA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:MALETA
Last Name:PITAMBER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1828
Mailing Address - Country:US
Mailing Address - Phone:516-489-6600
Mailing Address - Fax:516-489-6640
Practice Address - Street 1:2 MAIN ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4020
Practice Address - Country:US
Practice Address - Phone:516-489-6600
Practice Address - Fax:516-489-6640
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011416363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02872411Medicaid
NY02872411Medicaid
NYA400005023Medicare PIN