Healthcare Provider Details

I. General information

NPI: 1538461082
Provider Name (Legal Business Name): LYNDA SURCK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2010
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 TELEPORT DR SUITE 207
STATEN ISLAND NY
10311-1006
US

IV. Provider business mailing address

2 TELEPORT DR SUITE 207
STATEN ISLAND NY
10311-1006
US

V. Phone/Fax

Practice location:
  • Phone: 718-273-5500
  • Fax: 718-273-3232
Mailing address:
  • Phone: 718-273-5500
  • Fax: 718-273-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008660
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: