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General NPI Number Information
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NPI Number | 1912192394
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Entity Type | Organization
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Legal Business Name | ST. NICHOLAS MEDICAL PC
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Dates
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Enumeration Date | 09/10/2007
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Last Update Date | 10/09/2008
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Provider Practice Location Address
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Address Line | 115 SAINT NICHOLAS AVE
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City | BROOKLYN
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State | NY
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Zip | 11237-3474
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Country | US
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Telephone | 718-418-8368
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Fax | 718-418-8716
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Provider Business Mailing Address
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Address Line | 115 SAINT NICHOLAS AVE
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City | BROOKLYN
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State | NY
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Zip | 11237-3474
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Country | US
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Telephone | 718-418-8368
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Fax | 718-418-8716
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MYAT SAN
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Credential | M.D
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Telephone | 718-418-8368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 231830
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License Number State | NY
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