Healthcare Provider Details

I. General information

NPI: 1245865864
Provider Name (Legal Business Name): BRANDON KAM SHIN LAU PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 BROADWAY 2ND FLOOR
NEW YORK NY
10007-2056
US

IV. Provider business mailing address

281 BROADWAY 2ND FLOOR
NEW YORK NY
10007-2056
US

V. Phone/Fax

Practice location:
  • Phone: 646-596-7386
  • Fax: 646-850-9326
Mailing address:
  • Phone: 646-596-7386
  • Fax: 646-850-9326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024792
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: