Provider Demographics
NPI:1437450657
Name:EXRA, AMY C
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:EXRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W 67TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-6237
Mailing Address - Country:US
Mailing Address - Phone:212-799-6700
Mailing Address - Fax:212-799-4533
Practice Address - Street 1:11 W 67TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-6237
Practice Address - Country:US
Practice Address - Phone:212-799-6700
Practice Address - Fax:212-799-4533
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032729174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY032729OtherLICENCE NUMBER