MEDICARE: MRS. PATTY LAI CHUN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	008089	NY
2	207N00000X	Dermatology Physician	008089-1	NY

General Provider Information

NPI Number	:	1194801506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PATTY LAI CHUN PA-C

Provider Business Mailing Address
First Line	:	727 N BROADWAY STE B4
Second Line	:
City	:	MASSAPEQUA
State	:	NY
Zip	:	11758-2348
Country	:	US
Telephone Number	:	516-799-0210
Fax Number	:	516-799-0247

Provider Business Practice Location Address
First Line	:	727 N BROADWAY STE B4
Second Line	:
City	:	MASSAPEQUA
State	:	NY
Zip	:	11758-2348
Country	:	US
Telephone Number	:	516-799-0210
Fax Number	:	516-799-0247

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	08/27/2020

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