Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208D00000X | General Practice Physician | P03275 | NY |
NPI | 1043754039 |
---|---|
Provider Name | Tariq Halasa |
First Address | Saint Louis, MO 63141-8252 |
Second Address | Brooklyn, NY 11237-4006 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2016 |
Last Update Date | 18/10/2021 |