Provider Demographics
NPI:1902951080
Name:PEGUES, MARY (PA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:PEGUES
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 1:265 W 138TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-2102
Mailing Address - Country:US
Mailing Address - Phone:212-281-1581
Mailing Address - Fax:212-932-6659
Practice Address - Street 1:264 W 118TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1620
Practice Address - Country:US
Practice Address - Phone:212-932-6500
Practice Address - Fax:212-932-6599
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001685-1363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001685-1OtherSTATE LICENSE NUMBER