Provider Demographics
NPI:1700877149
Name:RESNIK, BRIAN MARC (PA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MARC
Last Name:RESNIK
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:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801
Mailing Address - Country:US
Mailing Address - Phone:518-926-6992
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:35 GILBERT ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12816
Practice Address - Country:US
Practice Address - Phone:518-677-3961
Practice Address - Fax:518-677-3180
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02347895Medicaid
P66921Medicare UPIN
NY02347895Medicaid