Provider Demographics
NPI:1134344997
Name:EUSTAQUIO, EDWIN S (PA)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:S
Last Name:EUSTAQUIO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:41 MEADOWWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735
Mailing Address - Country:US
Mailing Address - Phone:516-756-1689
Mailing Address - Fax:
Practice Address - Street 1:888 FOUNTAIN AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208
Practice Address - Country:US
Practice Address - Phone:718-642-6063
Practice Address - Fax:718-642-3857
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0046351363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical