Provider Demographics
NPI:1891317244
Name:PENNISE, ALEXANDER JOSEPH (PA)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:JOSEPH
Last Name:PENNISE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 E 74TH ST APT 17
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-3950
Mailing Address - Country:US
Mailing Address - Phone:585-831-7672
Mailing Address - Fax:
Practice Address - Street 1:715 9TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:212-757-3859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-08
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025458363A00000X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program