Provider Demographics
NPI:1053617324
Name:TOTESAU-JOHNSON, PRESTON DARIAN (PA)
Entity type:Individual
Prefix:MR
First Name:PRESTON
Middle Name:DARIAN
Last Name:TOTESAU-JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4024
Mailing Address - Country:US
Mailing Address - Phone:917-216-1142
Mailing Address - Fax:
Practice Address - Street 1:66 FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-4024
Practice Address - Country:US
Practice Address - Phone:917-216-1142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014007363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical