Healthcare Provider Details

I. General information

NPI: 1538635636
Provider Name (Legal Business Name): RACHEL SHADROUZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RACHEL SHADROUZ PA

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 SCHENECTADY AVE
BROOKLYN NY
11203-1822
US

IV. Provider business mailing address

1724 E 23RD ST
BROOKLYN NY
11229-1521
US

V. Phone/Fax

Practice location:
  • Phone: 718-604-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number022834
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: