Provider Demographics
NPI:1841418480
Name:GENTILE, THERESA M (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:M
Last Name:GENTILE
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6011 251ST ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-2433
Mailing Address - Country:US
Mailing Address - Phone:917-748-4507
Mailing Address - Fax:
Practice Address - Street 1:45 CROSSWAYS PARK DR W
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2037
Practice Address - Country:US
Practice Address - Phone:516-992-4568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006482363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant