Provider Demographics
NPI:1093190001
Name:CARDOSO, PABLO
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:
Last Name:CARDOSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 W 142ND ST APT 9C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1110
Mailing Address - Country:US
Mailing Address - Phone:646-755-1059
Mailing Address - Fax:
Practice Address - Street 1:71 METROPOLITAN OVAL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-6402
Practice Address - Country:US
Practice Address - Phone:718-597-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018908-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant