| | Physician Last Name: | Providian Medical |
| | Physician First Name: | P.C. |
| | Physician Middle Name: | |
| | Address: | 87-14 116th Street
Richmond Hill, New York |
| | License Number: | 094241 |
| | License Type: | |
| | Year of Birth: |
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| | Effective Date: | 05/15/2007 |
| | Action Description for DOH Webpage: | Annulment of certificate of incorporation pursuant to Section 230-a of the New York State Public Health Law and Section 1503(d) of the New York State Business Corporation Law |
| | Misconduct Description for DOH Webpage: | Failure to comply with Section 1503 of the New York State Business Corporation Law. |
| | License Limitations or Conditions for DOH Webpage: | |
| | Board Order: |
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