Healthcare Provider Details

I. General information

NPI: 1467450890
Provider Name (Legal Business Name): IAN D. DARE RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PALISADES DR
ALBANY NY
12205-1438
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-458-2000
  • Fax: 518-458-1524
Mailing address:
  • Phone: 518-525-5634
  • Fax: 518-649-4094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000993
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000993
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: