Healthcare Provider Details

I. General information

NPI: 1104690676
Provider Name (Legal Business Name): MASOOD TEMITOPE USMAN PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 E 87TH ST
BROOKLYN NY
11236-5137
US

IV. Provider business mailing address

1445 E 87TH ST
BROOKLYN NY
11236-5137
US

V. Phone/Fax

Practice location:
  • Phone: 917-705-5767
  • Fax:
Mailing address:
  • Phone: 917-705-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: