Basic Information
| Provider Information | |||||||||
| NPI: | 1841584489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EUASHACHAI | ||||||||
| FirstName: | MARENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARK STREET | ||||||||
| Address2: | GLENS FALLS HOSPITAL - CREDENTIALING | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189265924 | ||||||||
| FaxNumber: | 5189266983 | ||||||||
| Practice Location | |||||||||
| Address1: | 13 PALMER AVE | ||||||||
| Address2: | EVERGREEN HEALTH CENTER | ||||||||
| City: | CORINTH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128221145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186546499 | ||||||||
| FaxNumber: | 5186547303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2011 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 271644 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine | 171100000X | A271644 | N | Other Service Providers | Acupuncturist |
ID Information
| ID | Type | State | Issuer | Description | 04060555 | 05 | NY | MEDICAID |