Healthcare Provider Details

I. General information

NPI: 1659969095
Provider Name (Legal Business Name): MITCHELL PENG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2020
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

16 LAWRENCE ST
NEW HYDE PARK NY
11040-1721
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-8874
  • Fax:
Mailing address:
  • Phone: 516-941-5645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number026478
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: