Healthcare Provider Details

I. General information

NPI: 1215017397
Provider Name (Legal Business Name): MARCO ANTONIO BERRONES JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 OLD COUNTRY RD
PLAINVIEW NY
11803-4914
US

IV. Provider business mailing address

972 BRUSH HOLLOW RD
WESTBURY NY
11590-1740
US

V. Phone/Fax

Practice location:
  • Phone: 516-719-3000
  • Fax:
Mailing address:
  • Phone: 516-876-5555
  • Fax: 516-876-1246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number008261-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00246075
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: