Healthcare Provider Details

I. General information

NPI: 1386629483
Provider Name (Legal Business Name): JOAN VENEROSA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 09/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S. PERRY ST. ST. MARY'S HOSPITAL FAM HLTH CNTR AT JOHNSTOWN PEDIATRI
JOHNSTOWN NY
12095
US

IV. Provider business mailing address

427 GUY PARK AVE - PRIMARY & SPECIALTY CARE DEPT. ST. MARY'S HOSPITAL AT AMSTERDAM
AMSTERDAM NY
12010
US

V. Phone/Fax

Practice location:
  • Phone: 518-762-3161
  • Fax: 518-762-6751
Mailing address:
  • Phone: 518-841-7430
  • Fax: 518-841-7121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010571
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: