Facts
- Status
- A
- Credential
- RD
- Type
- Individual
- Enumeration date
- 2025-03-24
- Last updated
- 2025-03-24
Specialties
Licenses
- License NY
- 012479-01
Location
- Practice location
- 3448 DEER CREST DR
- City
- PAINTED POST NY
- Postal code
- 148709082
- Phone
- 607-346-7658
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.