Healthcare Provider Details

I. General information

NPI: 1619926151
Provider Name (Legal Business Name): HEROLD LESSAGE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 6TH ST
BROOKLYN NY
11215-3609
US

IV. Provider business mailing address

506 6TH ST
BROOKLYN NY
11215-3609
US

V. Phone/Fax

Practice location:
  • Phone: 718-780-3000
  • Fax:
Mailing address:
  • Phone: 718-780-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number008198
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: