Healthcare Provider Details

I. General information

NPI: 1326253642
Provider Name (Legal Business Name): SUDHA K OMPRAKASH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 BARD AVE
STATEN ISLAND NY
10310-1664
US

IV. Provider business mailing address

31 NORMAN PL
STATEN ISLAND NY
10309-4015
US

V. Phone/Fax

Practice location:
  • Phone: 718-818-3260
  • Fax: 718-818-3713
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number005194
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: