Provider Demographics
NPI:1750512018
Name:PELLEGRINO, BOBBI ALFRED (PA-C)
Entity Type:Individual
Prefix:
First Name:BOBBI
Middle Name:ALFRED
Last Name:PELLEGRINO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 TARGEE STREET
Mailing Address - Street 2:ADMINISTRATION
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4310
Mailing Address - Country:US
Mailing Address - Phone:718-448-3210
Mailing Address - Fax:718-720-1271
Practice Address - Street 1:1099 TARGEE STREET
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4310
Practice Address - Country:US
Practice Address - Phone:718-448-3210
Practice Address - Fax:718-815-3379
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013458363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03226386Medicaid