Healthcare Provider Details

I. General information

NPI: 1174192082
Provider Name (Legal Business Name): ILLAPA SAIRITUPAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 SAINT MARKS PL
NEW YORK NY
10003-7902
US

IV. Provider business mailing address

272 BOWERY
NEW YORK NY
10012-3674
US

V. Phone/Fax

Practice location:
  • Phone: 212-982-3470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: