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General NPI Number Information
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NPI Number | 1275671323
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Entity Type | Individual
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Provider Name | IAN CHARLES LORD I PA
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Gender | Male
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 506 MALCOLM X BLVD
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City | NEW YORK
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State | NY
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Zip | 10037-1802
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Country | US
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Telephone | 212-989-4680
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Fax |
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Provider Business Mailing Address
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Address Line | 277 MILLBROOK AVE
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City | RANDOLPH
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State | NJ
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Zip | 07869-2105
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Country | US
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Telephone | 973-607-1739
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 009863
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License Number State | NY
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