Provider Demographics
NPI:1285664425
Name:O'BRIEN, DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4300
Mailing Address - Fax:
Practice Address - Street 1:241 NORTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1154
Practice Address - Country:US
Practice Address - Phone:845-431-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23-007733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02383062Medicaid
NY4128281OtherMVP
NY02383062Medicaid
NY5F6251Medicare ID - Type Unspecified
NYP00309275Medicare PIN