Healthcare Provider Details

I. General information

NPI: 1225742059
Provider Name (Legal Business Name): YIANNIS NICK KEFALAS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E 77TH ST
NEW YORK NY
10075-1850
US

IV. Provider business mailing address

100 E 77TH ST
NEW YORK NY
10075-1850
US

V. Phone/Fax

Practice location:
  • Phone: 212-434-2000
  • Fax:
Mailing address:
  • Phone: 212-434-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: