Provider Demographics
NPI:1922668870
Name:GOVERNALE, TERESAMARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:TERESAMARIE
Middle Name:
Last Name:GOVERNALE
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 1:1428 157TH ST
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-2717
Mailing Address - Country:US
Mailing Address - Phone:347-256-6854
Mailing Address - Fax:
Practice Address - Street 1:1428 157TH ST
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-2717
Practice Address - Country:US
Practice Address - Phone:347-256-6854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant