Healthcare Provider Details

I. General information

NPI: 1144567124
Provider Name (Legal Business Name): SYED HAQUE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16806 HILLSIDE AVE
JAMAICA NY
11432-4341
US

IV. Provider business mailing address

1759 POWERS AVE
EAST MEADOW NY
11554-3935
US

V. Phone/Fax

Practice location:
  • Phone: 718-739-7400
  • Fax:
Mailing address:
  • Phone: 516-368-4433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0163041
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: