Provider Demographics
NPI:1972862845
Name:CHANG, KAROLYN A (PA)
Entity Type:Individual
Prefix:
First Name:KAROLYN
Middle Name:A
Last Name:CHANG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 BROADWAY
Mailing Address - Street 2:APT #14
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701
Mailing Address - Country:US
Mailing Address - Phone:516-551-0862
Mailing Address - Fax:
Practice Address - Street 1:670 STONELEIGH AVENUE
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512
Practice Address - Country:US
Practice Address - Phone:845-278-5687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23015501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant