Healthcare Provider Details

I. General information

NPI: 1508465139
Provider Name (Legal Business Name): ANDREA BUKALAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2020
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 FRANKLIN AVE
GARDEN CITY NY
11530-1617
US

IV. Provider business mailing address

21 BARSTOW RD APT 2F
GREAT NECK NY
11021-2203
US

V. Phone/Fax

Practice location:
  • Phone: 516-344-0165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024776
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: