Provider Demographics
NPI:1063774578
Name:PENNISI, MARIA A (P A)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:A
Last Name:PENNISI
Suffix:
Gender:F
Credentials:P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 STOCKHOLM ST
Mailing Address - Street 2:C/O FACULTY PRACTICE MANAGEMENT- SUITE 1-37N
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4006
Mailing Address - Country:US
Mailing Address - Phone:718-963-6485
Mailing Address - Fax:
Practice Address - Street 1:374 STOCKHOLM ST
Practice Address - Street 2:C/O FACULTY PRACTICE MANAGEMENT- SUITE 1-37N
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4006
Practice Address - Country:US
Practice Address - Phone:718-963-6485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant