Individual
MR. LUIS A BLANCO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
10211 ROOSEVELT AVE, CORONA, NY 11368-2331
(718) 898-1386
(718) 898-1093
Mailing address
25 JACKSON AVE, WHITE PLAINS, NY 10606-2216
(917) 572-6810
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
005075-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
005075-1
LICENSE NO
NY
Enumeration date
02/16/2010
Last updated
04/19/2018
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