MEDICARE: GINNA MARIEL LORA ORTEGA PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	PA9115070	FL
2	363A00000X	Physician Assistant	029359	NY

General Provider Information

NPI Number	:	1659043925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINNA MARIEL LORA ORTEGA PA

Provider Business Mailing Address
First Line	:	2626 HALPERIN AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-2631
Country	:	US
Telephone Number	:	718-618-0461
Fax Number	:	718-537-6180

Provider Business Practice Location Address
First Line	:	2626 HALPERIN AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-2631
Country	:	US
Telephone Number	:	718-583-7736
Fax Number	:	718-537-6180

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2021
Last Update Date	:	01/09/2023

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