Healthcare Provider Details

I. General information

NPI: 1215171038
Provider Name (Legal Business Name): SHERLY ALTIDOR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 10TH AVE # 2T
NEW YORK NY
10019-1147
US

IV. Provider business mailing address

1000 10TH AVE # 2T
NEW YORK NY
10019-1147
US

V. Phone/Fax

Practice location:
  • Phone: 212-523-6500
  • Fax: 212-523-7182
Mailing address:
  • Phone: 212-523-6500
  • Fax: 212-523-7182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005773
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: