Provider Demographics
NPI:1720210792
Name:PATERNOSTER, TARA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:PATERNOSTER
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 1:2001 MARCUS AVE STE E249
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1000
Mailing Address - Country:US
Mailing Address - Phone:516-437-5600
Mailing Address - Fax:
Practice Address - Street 1:2001 MARCUS AVE STE E249
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1000
Practice Address - Country:US
Practice Address - Phone:516-437-5600
Practice Address - Fax:516-437-5600
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013428363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04297114Medicaid