Healthcare Provider Details

I. General information

NPI: 1114249786
Provider Name (Legal Business Name): GISELLE RENDON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27005 76TH AVE
NEW HYDE PARK NY
11040-1402
US

IV. Provider business mailing address

9610 40TH RD FL 2
CORONA NY
11368-2139
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-7330
  • Fax:
Mailing address:
  • Phone: 917-515-9299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number013873
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: