Healthcare Provider Details

I. General information

NPI: 1700877149
Provider Name (Legal Business Name): BRIAN MARC RESNIK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 GILBERT ST
CAMBRIDGE NY
12816
US

IV. Provider business mailing address

PO BOX 304
GLENS FALLS NY
12801
US

V. Phone/Fax

Practice location:
  • Phone: 518-677-3961
  • Fax: 518-677-3180
Mailing address:
  • Phone: 518-926-6992
  • Fax: 518-926-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005152
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: