Provider Demographics
NPI:1639927866
Name:LEGARDYE, BYRON (CPRA)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:
Last Name:LEGARDYE
Suffix:
Gender:M
Credentials:CPRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 RIVER AVE APT 801
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-8494
Mailing Address - Country:US
Mailing Address - Phone:718-964-8613
Mailing Address - Fax:
Practice Address - Street 1:1169 RIVER AVE APT 801
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-8494
Practice Address - Country:US
Practice Address - Phone:718-964-8613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCPRA6163174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCPRA6163Medicaid