Provider Demographics
NPI:1598004582
Name:MODI, MANOJ (RPA-C,MPAS)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:
Last Name:MODI
Suffix:
Gender:M
Credentials:RPA-C,MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 N ONTARIO AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2222
Mailing Address - Country:US
Mailing Address - Phone:917-306-5532
Mailing Address - Fax:
Practice Address - Street 1:2001 MARCUS AVE STE W170
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2042
Practice Address - Country:US
Practice Address - Phone:516-355-0111
Practice Address - Fax:516-355-9420
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant