Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152W00000X | Optometrist | 007777 | NY |
Y | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 007777 | NY |
NPI | 1205115474 |
---|---|
Provider Name | Miss Angela V Dussan |
First Address | Long Island City, NY 11101-6273 |
Second Address | Long Island City, NY 11101-6273 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2011 |
Last Update Date | 23/08/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1205115474 | (05) | NY |