Basic Information
| Provider Information | |||||||||
| NPI: | 1154334761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAGAN | ||||||||
| FirstName: | NANCY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 ST. JOHN'S PL APT 1B | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175837900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 E 68TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100654870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127465026 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 09/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 007161 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 00245643 | 05 | NY | MEDICAID | 02396743 | 05 | NY | MEDICAID |