Provider Demographics
NPI:1346592235
Name:ACOSTA, ENRIQUE ALEXANDER (PA)
Entity type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:ALEXANDER
Last Name:ACOSTA
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Gender:M
Credentials:PA
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Mailing Address - Street 1:227 MADISON ST
Mailing Address - Street 2:MEDICAL STAFF OFFICE , R -1249
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-7537
Mailing Address - Country:US
Mailing Address - Phone:212-238-7614
Mailing Address - Fax:212-238-7009
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:MEDICAL STAFF OFFICE , R -1249
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7614
Practice Address - Fax:212-238-7009
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2013-01-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY016338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016338OtherNYS PHYSICIAN ASSISTANT LICENSE