Provider Demographics
NPI:1790918415
Name:MAGEGE, ESEROGHENE (PA)
Entity Type:Individual
Prefix:
First Name:ESEROGHENE
Middle Name:
Last Name:MAGEGE
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 1:31 DOREEN DR
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2136
Mailing Address - Country:US
Mailing Address - Phone:917-723-5656
Mailing Address - Fax:
Practice Address - Street 1:9807 FOSTER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-2113
Practice Address - Country:US
Practice Address - Phone:347-435-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY.....363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant