Healthcare Provider Details

I. General information

NPI: 1841372083
Provider Name (Legal Business Name): HALSEY CRUICKSHANK PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1276 FULTON AVE
BRONX NY
10456-3402
US

IV. Provider business mailing address

1431 E 108TH ST SUITE D
BROOKLYN NY
11236-4666
US

V. Phone/Fax

Practice location:
  • Phone: 718-901-8792
  • Fax: 718-901-8799
Mailing address:
  • Phone: 718-763-5093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003540
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: