Provider Demographics
NPI:1033469077
Name:BREA, RADARANYS (PA)
Entity Type:Individual
Prefix:MISS
First Name:RADARANYS
Middle Name:
Last Name:BREA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 BURRSTONE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1001
Mailing Address - Country:US
Mailing Address - Phone:315-798-1702
Mailing Address - Fax:
Practice Address - Street 1:1729 BURRSTONE RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1001
Practice Address - Country:US
Practice Address - Phone:315-798-1702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015979363A00000X, 363AM0700X
NY159791363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03553495Medicaid