Provider Demographics
NPI:1841248747
Name:DEMAREST, MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DEMAREST
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E 77TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-1850
Mailing Address - Country:US
Mailing Address - Phone:212-434-2650
Mailing Address - Fax:212-434-4512
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-1850
Practice Address - Country:US
Practice Address - Phone:212-434-2650
Practice Address - Fax:212-434-4512
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01868506Medicaid
S57626Medicare UPIN
NJ187318UA1Medicare PIN
NY0F0011Medicare PIN
NY01868506Medicaid
NYA40101007752Medicare PIN