Provider Demographics
NPI:1013664358
Name:TAK, KIRAN VINAY (PA-C)
Entity Type:Individual
Prefix:
First Name:KIRAN
Middle Name:VINAY
Last Name:TAK
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 1:7901 BROADWAY # D3-16
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-2548
Mailing Address - Fax:718-334-5006
Practice Address - Street 1:7901 BROADWAY # D3-16
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-2548
Practice Address - Fax:718-334-5006
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027874-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant