Basic Information
| Provider Information | |||||||||
| NPI: | 1144289745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRY | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1628 LINCOLN PL | ||||||||
| Address2: | 4H | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112335128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184939119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 451 CLARKSON AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182453131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 005377 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.