Provider Demographics
NPI:1073368924
Name:PTAK, CHRISTOPHER (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:PTAK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PARKWOLD DR W
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-2130
Mailing Address - Country:US
Mailing Address - Phone:516-547-7236
Mailing Address - Fax:
Practice Address - Street 1:5626 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-4736
Practice Address - Country:US
Practice Address - Phone:718-571-9714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031790363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant