Provider Demographics
NPI:1114761798
Name:TRAILLE, ALISHA SIMONE
Entity type:Individual
Prefix:MS
First Name:ALISHA
Middle Name:SIMONE
Last Name:TRAILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19435 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2022
Mailing Address - Country:US
Mailing Address - Phone:347-430-9304
Mailing Address - Fax:
Practice Address - Street 1:2001 MARCUS AVE STE S160
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1011
Practice Address - Country:US
Practice Address - Phone:516-519-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311632207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine