Provider Demographics
NPI:1881719987
Name:URIBE, RODOLFO (PA C)
Entity type:Individual
Prefix:
First Name:RODOLFO
Middle Name:
Last Name:URIBE
Suffix:
Gender:M
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 1:86 11 188TH STREET
Mailing Address - Street 2:
Mailing Address - City:HOLLISWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11423
Mailing Address - Country:US
Mailing Address - Phone:718-479-4731
Mailing Address - Fax:
Practice Address - Street 1:2253 3RD AVE
Practice Address - Street 2:3RD FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035
Practice Address - Country:US
Practice Address - Phone:212-289-6650
Practice Address - Fax:212-360-6149
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00005742363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00005853Medicaid