Healthcare Provider Details

I. General information

NPI: 1750773149
Provider Name (Legal Business Name): KRYSTLE HSU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7404
US

IV. Provider business mailing address

6889 CLARET CIR
FAYETTEVILLE NY
13066-1048
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6262
  • Fax:
Mailing address:
  • Phone: 315-445-9455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0184101
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: