=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174823777
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY RAJAN PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2010
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27005 76TH AVE
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-470-7898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1871 BELTAGH PL
-----------------------------------------------------
City | NORTH BELLMORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11710-2940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-226-4684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 014189-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------