Healthcare Provider Details

I. General information

NPI: 1740904218
Provider Name (Legal Business Name): DONNA GWAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 AMSTERDAM AVE
NEW YORK NY
10025-1716
US

IV. Provider business mailing address

1111 AMSTERDAM AVE
NEW YORK NY
10025-1716
US

V. Phone/Fax

Practice location:
  • Phone: 212-523-3981
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number028875
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: