Healthcare Provider Details

I. General information

NPI: 1720815475
Provider Name (Legal Business Name): MARIA GUADALUPE ESCOBAR QUINONEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BETHPAGE RD STE 310
HICKSVILLE NY
11801-1515
US

IV. Provider business mailing address

PO BOX 1121
PORT WASHINGTON NY
11050-7121
US

V. Phone/Fax

Practice location:
  • Phone: 516-822-6655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: