Healthcare Provider Details

I. General information

NPI: 1245076355
Provider Name (Legal Business Name): NORTHERN WESTCHESTER FACULTY MEDICAL AFFILIATES, UNIVERSITY FACULTY PR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E MAIN ST
MOUNT KISCO NY
10549-3417
US

IV. Provider business mailing address

400 E MAIN ST
MOUNT KISCO NY
10549-3417
US

V. Phone/Fax

Practice location:
  • Phone: 914-666-1200
  • Fax: 914-242-8363
Mailing address:
  • Phone: 914-666-1200
  • Fax: 914-242-8363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: COLLEEN U INGRASSIA
Title or Position: PHYSICIAN ASSISTANT
Credential: PA
Phone: 914-666-1200