Provider Demographics
NPI:1710687199
Name:CAPITAL CITY GOSPEL MISSION FREE CLINIC
Entity Type:Organization
Organization Name:CAPITAL CITY GOSPEL MISSION FREE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZERONDA
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:518-533-5415
Mailing Address - Street 1:259 S PEARL ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12202-1859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:88 TRINITY PLACE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12202
Practice Address - Country:US
Practice Address - Phone:518-533-5415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAPITAL CITY GOSPEL MISSION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty