Basic Information
| Provider Information | |||||||||
| NPI: | 1952411936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARINA | ||||||||
| FirstName: | MARYANNE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PATRIOTS RD | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117903318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314448608 | ||||||||
| FaxNumber: | 6314448778 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PATRIOTS RD | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117903318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314448608 | ||||||||
| FaxNumber: | 6314448778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 12/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/27/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 000887 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 004187466 | 05 | CT | MEDICAID |