Healthcare Provider Details

I. General information

NPI: 1487076337
Provider Name (Legal Business Name): ALLA SKOVPENYA R-PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 01/13/2014
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

355 BARD AVE
STATEN ISLAND NY
10310-1664
US

V. Phone/Fax

Practice location:
  • Phone: 718-818-1234
  • Fax:
Mailing address:
  • Phone: 718-818-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number017259
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: