Provider Demographics
NPI:1316126287
Name:HEREDIA, DERLY M (PA)
Entity type:Individual
Prefix:MS
First Name:DERLY
Middle Name:M
Last Name:HEREDIA
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Gender:F
Credentials:PA
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Mailing Address - Street 1:4028 82ND ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1305
Mailing Address - Country:US
Mailing Address - Phone:718-478-0338
Mailing Address - Fax:718-478-6050
Practice Address - Street 1:4028 82ND ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1305
Practice Address - Country:US
Practice Address - Phone:718-478-0338
Practice Address - Fax:718-478-6050
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
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Provider Licenses
StateLicense IDTaxonomies
NY011032363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical