Provider Demographics
NPI:1053892711
Name:JOHN, CHRISTINE ANN (PA)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ANN
Last Name:JOHN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-5031
Mailing Address - Country:US
Mailing Address - Phone:516-661-6760
Mailing Address - Fax:
Practice Address - Street 1:210 E 64TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-7471
Practice Address - Country:US
Practice Address - Phone:516-661-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0224031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant