Healthcare Provider Details

I. General information

NPI: 1407165780
Provider Name (Legal Business Name): KOBINA DWIRA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SEMINARY HILL RD
CARMEL NY
10512-1921
US

IV. Provider business mailing address

23 E 3RD ST APT D23
MOUNT VERNON NY
10550-3980
US

V. Phone/Fax

Practice location:
  • Phone: 845-225-3400
  • Fax: 845-704-6178
Mailing address:
  • Phone: 646-713-7817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number014166
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: