=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699840843
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARLENE MALETA PITAMBER PHYSICIAN ASSISTANT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2006
-----------------------------------------------------
Last Update Date | 10/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 MAIN ST
-----------------------------------------------------
City | HEMPSTEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11550-4020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-489-6600
-----------------------------------------------------
Fax | 516-489-6640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 627 PEARL ST
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11572-1828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-489-6600
-----------------------------------------------------
Fax | 516-489-6640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 011416
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------