Healthcare Provider Details

I. General information

NPI: 1003133752
Provider Name (Legal Business Name): ANGELICA LYTE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14520 106TH AVE
JAMAICA NY
11435-5004
US

IV. Provider business mailing address

2601 OCEAN PKWY
BROOKLYN NY
11235-7745
US

V. Phone/Fax

Practice location:
  • Phone: 917-674-2842
  • Fax:
Mailing address:
  • Phone: 718-616-4387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number013786
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: