Provider Demographics
NPI:1093892267
Name:KAGAN, BROCHA FAYGE (PA)
Entity Type:Individual
Prefix:
First Name:BROCHA
Middle Name:FAYGE
Last Name:KAGAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CATON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1617
Mailing Address - Country:US
Mailing Address - Phone:718-215-8650
Mailing Address - Fax:718-780-7380
Practice Address - Street 1:506 6TH ST
Practice Address - Street 2:NEW YORK METHODIST HOSPITAL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3609
Practice Address - Country:US
Practice Address - Phone:718-780-3159
Practice Address - Fax:718-780-7380
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010454363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid