Provider Demographics
NPI:1770289779
Name:PAREDES REYES, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:PAREDES REYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 HARMAN ST # 2R
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1924
Mailing Address - Country:US
Mailing Address - Phone:631-339-4152
Mailing Address - Fax:
Practice Address - Street 1:2026 HARMAN ST # 2R
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1924
Practice Address - Country:US
Practice Address - Phone:631-339-4152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1548-P.A.363A00000X
FLTPPA737363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1548-P.AOtherPA