Provider Demographics
NPI:1730109406
Name:PESOLA, MARIE CAMERON (PA)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:CAMERON
Last Name:PESOLA
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 1:575 GRAND ST APT E1905
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-4321
Mailing Address - Country:US
Mailing Address - Phone:212-982-1708
Mailing Address - Fax:
Practice Address - Street 1:575 GRAND ST APT E1905
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4321
Practice Address - Country:US
Practice Address - Phone:212-982-1708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03751333Medicaid
NY03751333Medicaid