Provider Demographics
NPI:1194898676
Name:BURRIS-WARMOTH, PATRICIA R (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:R
Last Name:BURRIS-WARMOTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14601 45TH AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2200
Mailing Address - Country:US
Mailing Address - Phone:718-670-5534
Mailing Address - Fax:718-670-3031
Practice Address - Street 1:80 MARCUS DR
Practice Address - Street 2:PROVIDER ENROLLMENT
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4230
Practice Address - Country:US
Practice Address - Phone:631-391-7889
Practice Address - Fax:631-454-4163
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198810207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01777462Medicaid
NYNYS LICENSEOther198810
NYG58688Medicare UPIN