MEDICARE: MRS. MACRINA M REYES RPAC MS

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	363A00000X	Physician Assistant	25MP00056000

General Provider Information

NPI Number	:	1659334993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MACRINA M REYES RPAC MS

Provider Business Mailing Address
First Line	:	57 SCHMIDTS LANE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314
Country	:	US
Telephone Number	:	718-982-9631
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 VICTORY BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-3623
Country	:	US
Telephone Number	:	718-273-2277
Fax Number	:	718-720-4989

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

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	07/08/2007

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