Healthcare Provider Details

I. General information

NPI: 1164542148
Provider Name (Legal Business Name): INGRID DEFREITAS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2007
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 23RD ST
ASTORIA NY
11106-4134
US

IV. Provider business mailing address

3175 23RD ST
ASTORIA NY
11106-4134
US

V. Phone/Fax

Practice location:
  • Phone: 516-542-6880
  • Fax: 516-542-5556
Mailing address:
  • Phone: 516-542-6880
  • Fax: 516-542-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number010128
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: