Provider Demographics
NPI:1770769861
Name:SUNG, EDDIE (PA)
Entity type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:
Last Name:SUNG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9002 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4941
Mailing Address - Country:US
Mailing Address - Phone:718-279-9461
Mailing Address - Fax:
Practice Address - Street 1:9002 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4941
Practice Address - Country:US
Practice Address - Phone:718-279-9461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011445363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant