Provider Demographics
NPI:1184752529
Name:DURIVAGE, MONICA CHURA (RPA-C)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:CHURA
Last Name:DURIVAGE
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MENEMSHA LN
Mailing Address - Street 2:
Mailing Address - City:WYNANTSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12198-3415
Mailing Address - Country:US
Mailing Address - Phone:518-276-6287
Mailing Address - Fax:518-276-8573
Practice Address - Street 1:110 8TH ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-3590
Practice Address - Country:US
Practice Address - Phone:518-276-6287
Practice Address - Fax:518-276-8573
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001773363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMD0690746OtherDEA