Provider Demographics
NPI:1851572655
Name:ANTOSZEWSKI, CLAIRE JOAN (PA)
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:JOAN
Last Name:ANTOSZEWSKI
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 1:453 1/2 AMADO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-3700
Mailing Address - Country:US
Mailing Address - Phone:203-249-3002
Mailing Address - Fax:
Practice Address - Street 1:453 1/2 AMADO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-3700
Practice Address - Country:US
Practice Address - Phone:203-249-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012262-1363A00000X
NMPA2010-0040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMA101172Medicare PIN