Healthcare Provider Details

I. General information

NPI: 1043667140
Provider Name (Legal Business Name): SHRIDEVI PERSAD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27005 76TH AVE
NEW HYDE PARK NY
11040-1402
US

IV. Provider business mailing address

3243 33RD ST
ASTORIA NY
11106-2127
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-7330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019671-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: