Individual
MR. ELLIOT S FORMAL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2510 30TH AVE, ASTORIA, NY 11102-2418
(718) 932-1000
Mailing address
3450 28TH ST APT 2H, ASTORIA, NY 11106-3533
(609) 502-3182
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
024373
NY
Other
Enumeration date
04/24/2019
Last updated
04/10/2023
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