Healthcare Provider Details

I. General information

NPI: 1891080800
Provider Name (Legal Business Name): AGELESS MEN'S HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 ATLANTIC AVE FL 2
BROOKLYN NY
11201-6792
US

IV. Provider business mailing address

161 ATLANTIC AVE FL 2
BROOKLYN NY
11201-6792
US

V. Phone/Fax

Practice location:
  • Phone: 212-430-6677
  • Fax:
Mailing address:
  • Phone: 212-430-6677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0068091
License Number StateNY

VIII. Authorized Official

Name: AMANDA WILKINSON
Title or Position: BUSINESS OPERATIONS DIRECTOR
Credential:
Phone: 702-818-0446