Healthcare Provider Details

I. General information

NPI: 1952455214
Provider Name (Legal Business Name): AVI TERRY P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 AMSTERDAM AVE
NEW YORK NY
10025-1716
US

IV. Provider business mailing address

270 RIVERSIDE DR APT 10C
NEW YORK NY
10025-5211
US

V. Phone/Fax

Practice location:
  • Phone: 212-523-5678
  • Fax: 212-523-3550
Mailing address:
  • Phone: 212-523-5678
  • Fax: 212-523-3550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number000768
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: