Provider Demographics
NPI:1265074280
Name:MORAN PENA, GABRIELLE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:GABRIELLE
Middle Name:
Last Name:MORAN PENA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4250 BROADWAY RM 1C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3768
Mailing Address - Country:US
Mailing Address - Phone:212-740-3900
Mailing Address - Fax:212-740-8232
Practice Address - Street 1:4250 BROADWAY RM 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3768
Practice Address - Country:US
Practice Address - Phone:212-740-3900
Practice Address - Fax:212-740-8232
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2024-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant