Provider Demographics
NPI:1710156708
Name:MIRROW, DAREENA D (PA)
Entity Type:Individual
Prefix:
First Name:DAREENA
Middle Name:D
Last Name:MIRROW
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:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-591-1121
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:2001 5TH AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-3340
Practice Address - Country:US
Practice Address - Phone:518-687-1960
Practice Address - Fax:518-687-1970
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003445363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY331943Medicare Oscar/Certification
NY363AM0700XOtherTAXONOMIES
NY00695941Medicaid