Provider Demographics
NPI:1902057227
Name:MOMBELEUR, HENRY ALIX (PA)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:ALIX
Last Name:MOMBELEUR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:HENRY
Other - Middle Name:ALIX
Other - Last Name:MOMBELEUR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:26 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-7601
Mailing Address - Country:US
Mailing Address - Phone:212-420-2078
Mailing Address - Fax:212-982-6990
Practice Address - Street 1:26 AVENUE A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009-7601
Practice Address - Country:US
Practice Address - Phone:212-420-2078
Practice Address - Fax:212-982-6990
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004034-1363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical