Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | 234866-1 | NY |
NPI | 1306040936 |
---|---|
Provider Name | Quentin Phung |
First Address | Clifton Park, NY 12065-3107 |
Second Address | Clifton Park, NY 12065-3107 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2007 |
Last Update Date | 07/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000418627001 | BSNENY PIN - SPECIALIST (01) | NY |
000418627005 | BSNENY PIN - ACUPUNTURIST (01) | NY |
03056902 | (05) | NY |