Healthcare Provider Details

I. General information

NPI: 1871948620
Provider Name (Legal Business Name): KLEMENTINA KOCI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 BAINBRIDGE AVE FL MAP33
BRONX NY
10467-2404
US

IV. Provider business mailing address

3400 BAINBRIDGE AVE FL MAP33
BRONX NY
10467-2404
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-6139
  • Fax: 718-515-7940
Mailing address:
  • Phone: 718-920-6139
  • Fax: 718-515-7940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number019240-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: