Provider Demographics
NPI:1558300350
Name:CHANG, BEVERLEY O (PA-C)
Entity Type:Individual
Prefix:
First Name:BEVERLEY
Middle Name:O
Last Name:CHANG
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 1:525 E 49TH ST
Mailing Address - Street 2:APT # 2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-4344
Mailing Address - Country:US
Mailing Address - Phone:718-753-4300
Mailing Address - Fax:
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2057
Practice Address - Country:US
Practice Address - Phone:718-245-4708
Practice Address - Fax:718-245-4725
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0104444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant