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General NPI Number Information
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NPI Number | 1952484719
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Entity Type | Individual
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Provider Name | IAN CARLO DEJESUS PA
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Gender | Male
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 760 BROADWAY
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City | BROOKLYN
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State | NY
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Zip | 11206-5317
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Country | US
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Telephone | 171-896-3837
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Fax |
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Provider Business Mailing Address
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Address Line | 20936 27TH AVE
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City | BAYSIDE
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State | NY
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Zip | 11360-2405
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Country | US
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Telephone | 718-428-2420
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | P47235
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License Number State | NY
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