Provider Demographics
NPI:1225367485
Name:AYALA, LUIS MANUEL JR (PA-C)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:MANUEL
Last Name:AYALA
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 BOND ST
Mailing Address - Street 2:APT. 3A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-2938
Mailing Address - Country:US
Mailing Address - Phone:718-243-0441
Mailing Address - Fax:
Practice Address - Street 1:161 ATLANTIC AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6720
Practice Address - Country:US
Practice Address - Phone:718-797-5504
Practice Address - Fax:718-797-5645
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY012754-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant