Provider Demographics
NPI:1881733103
Name:ANTONIO, JUSTINA AGUIRRE (PA)
Entity type:Individual
Prefix:
First Name:JUSTINA
Middle Name:AGUIRRE
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 FRANKLIN AVE
Mailing Address - Street 2:UNIT 1C
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-3848
Mailing Address - Country:US
Mailing Address - Phone:914-686-5138
Mailing Address - Fax:
Practice Address - Street 1:80 MILL RIVER ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3733
Practice Address - Country:US
Practice Address - Phone:203-348-7410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001391363A00000X
NY007274-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant