Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 344497 | NY |
N | 207QS0010X | Family Doctor - Sports Medicine | 344497 | NY |
NPI | 1093367294 |
---|---|
Provider Name | Kenya Crafton |
First Address | Freeport, NY 11520-1205 |
Second Address | Oceanside, NY 11572-1551 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2019 |
Last Update Date | 09/07/2019 |