Healthcare Provider Details

I. General information

NPI: 1366473167
Provider Name (Legal Business Name): ILIRIANA SELA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

1 EDGEWATER STREET SUITE 723
STATEN ISLAND NY
10305
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-9158
  • Fax:
Mailing address:
  • Phone: 718-226-4324
  • Fax: 718-226-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number010912
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: