Provider Demographics
NPI:1902635626
Name:HARRY, BERTRAM (PA-C)
Entity type:Individual
Prefix:
First Name:BERTRAM
Middle Name:
Last Name:HARRY
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 1:13925 231ST ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2926
Mailing Address - Country:US
Mailing Address - Phone:347-277-3976
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-4826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032955-01390200000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program