Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2023-03-29
- Last updated
- 2026-06-01
Licenses
- License NY
- 036450
- License PA
- PENDING
Location
- Practice location
- 165 CHARLES ST
- City
- PAINTED POST NY
- Postal code
- 148701100
- Phone
- 607-936-3704
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.