Healthcare Provider Details

I. General information

NPI: 1407039613
Provider Name (Legal Business Name): VERONIQUE CAMILLE PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

1348 E 59TH ST
BROOKLYN NY
11234-4124
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-2961
  • Fax:
Mailing address:
  • Phone: 718-763-9394
  • Fax: 718-920-2961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number005039
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: