Provider Demographics
NPI:1497390108
Name:BRUCKSTEIN, RACHEL (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:BRUCKSTEIN
Suffix:
Gender:F
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 1:8519 ABINGDON RD
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-2701
Mailing Address - Country:US
Mailing Address - Phone:718-463-8787
Mailing Address - Fax:
Practice Address - Street 1:8519 ABINGDON RD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-2701
Practice Address - Country:US
Practice Address - Phone:718-463-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant