MEDICARE: MR. ANGEL SALVADOR MAITA-ZAPATA PHYSICIAN ASSISTANT

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	363AM0700X	Medical Physician Assistant	6705	CT
2	363AM0700X	Medical Physician Assistant	PA101603	MA
3	363AM0700X	Medical Physician Assistant	25MP00820700	NJ
4	363AM0700X	Medical Physician Assistant	027553	NY

General Provider Information

NPI Number	:	1871773358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANGEL SALVADOR MAITA-ZAPATA PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	3085 E MAIN ST STE 12A
Second Line	:
City	:	MOHEGAN LAKE
State	:	NY
Zip	:	10547-1542
Country	:	US
Telephone Number	:	860-650-3848
Fax Number	:

Provider Business Practice Location Address
First Line	:	3085 E MAIN ST STE 12A
Second Line	:
City	:	MOHEGAN LAKE
State	:	NY
Zip	:	10547-1542
Country	:	US
Telephone Number	:	860-650-3848
Fax Number	:

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

Provider Enumeration Date	:	11/13/2007
Last Update Date	:	04/23/2025

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