Provider Demographics
NPI:1700587110
Name:LOUIS, JUNIOR
Entity Type:Individual
Prefix:
First Name:JUNIOR
Middle Name:
Last Name:LOUIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 US ROUTE 11 APT S3
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:13795-1662
Mailing Address - Country:US
Mailing Address - Phone:607-727-0672
Mailing Address - Fax:
Practice Address - Street 1:933 US ROUTE 11 APT S3
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:NY
Practice Address - Zip Code:13795-1662
Practice Address - Country:US
Practice Address - Phone:607-727-0672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001361-P.A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant