Healthcare Provider Details

I. General information

NPI: 1649335274
Provider Name (Legal Business Name): ANDREW WALTER DOUGLAS RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3RD AVE AND 183RD STR
BRONX NY
10457-2594
US

IV. Provider business mailing address

304 W 148TH ST APT 2A
NEW YORK NY
10039-2915
US

V. Phone/Fax

Practice location:
  • Phone: 718-960-9000
  • Fax:
Mailing address:
  • Phone: 570-660-7085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number011617
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: