Provider Demographics
NPI:1699163774
Name:KATANOVA, MARINA (PA)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:KATANOVA
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 1:6550 WETHEROLE ST APT 1U
Mailing Address - Street 2:APT 1U
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4715
Mailing Address - Country:US
Mailing Address - Phone:347-612-2547
Mailing Address - Fax:
Practice Address - Street 1:2510 30TH AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11102-2448
Practice Address - Country:US
Practice Address - Phone:718-267-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-24
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant