=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497875975
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY JOSEPH RECIO SANTOS PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2007
-----------------------------------------------------
Last Update Date | 04/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 LAKEVILLE RD
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11042-1121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-470-8957
-----------------------------------------------------
Fax | 718-413-1913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 972 BRUSH HOLLOW RD
-----------------------------------------------------
City | WESTBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11590-1740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-876-5555
-----------------------------------------------------
Fax | 516-876-1246
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 006837
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------