Provider Demographics
NPI:1588894893
Name:ITZHAK, GREGORY (PA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:ITZHAK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9820 62ND DR
Mailing Address - Street 2:APT. 4-G
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1745
Mailing Address - Country:US
Mailing Address - Phone:917-528-6839
Mailing Address - Fax:
Practice Address - Street 1:4377 BRONX BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1397
Practice Address - Country:US
Practice Address - Phone:718-325-0700
Practice Address - Fax:718-325-1301
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY012850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMI1884837OtherDEA