Provider Demographics
NPI:1992705834
Name:PEREZ, MARIA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 BARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-2409
Mailing Address - Country:US
Mailing Address - Phone:203-333-6864
Mailing Address - Fax:203-332-0376
Practice Address - Street 1:471 BARNUM AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-2409
Practice Address - Country:US
Practice Address - Phone:203-333-6864
Practice Address - Fax:203-332-0376
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001564OtherSTATE LICENSE
CT001564OtherSTATE LICENSE
CT970001783Medicare PIN