Provider Demographics
NPI:1023663184
Name:WOOD-MINARDI, GENEVIEVE (PA)
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:WOOD-MINARDI
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 1:107 N OCEAN AVE STE G
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2012
Mailing Address - Country:US
Mailing Address - Phone:631-654-5004
Mailing Address - Fax:631-654-5048
Practice Address - Street 1:236 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-6289
Practice Address - Country:US
Practice Address - Phone:718-307-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY024594363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024594-01OtherREGISTRATION CERTIFICATE