Provider Demographics
NPI:1124650056
Name:COVA SALAZAR, LUIS EDGARDO (SA-C)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:EDGARDO
Last Name:COVA SALAZAR
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3549 166TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1722
Mailing Address - Country:US
Mailing Address - Phone:347-772-0577
Mailing Address - Fax:
Practice Address - Street 1:3549 166TH ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1722
Practice Address - Country:US
Practice Address - Phone:347-772-0577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19-414246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant