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General NPI Number Information
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NPI Number | 1639981749
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Entity Type | Individual
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Provider Name | MATTHEW DERMKSIAN
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Gender | Male
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Dates
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Enumeration Date | 01/24/2025
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Last Update Date | 01/26/2025
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Provider Practice Location Address
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Address Line | 622 W 168TH ST
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City | NEW YORK
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State | NY
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Zip | 10032-3720
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Country | US
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Telephone | 212-305-8312
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Fax |
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Provider Business Mailing Address
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Address Line | 203 LEGEND DR APT 2407
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City | SLEEPY HOLLOW
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State | NY
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Zip | 10591-2965
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Country | US
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Telephone |
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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 |
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License Number State |
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