Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 053055-1 | NY |
Y | 213EG0000X | General Practice | 053055-1 | NY |
NPI | 1003098476 |
---|---|
Provider Name | Hanna Song |
First Address | Brentwood, NY 11717-4210 |
Second Address | Brentwood, NY 11717-4210 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2007 |
Last Update Date | 30/11/2016 |