Park Avenue New York, NY 10021 NPI: 1932138231 DEANumber: BK0650831 Electronically Signed By (SP0: 6755230500004 Diagnosis Code: Eloctrod=alb• Troosm hod To: Publix N1395 Palm Beach 135 IPadloy PI Palm Eoach. rL a)dacce19 Prescriber Order U: 11180476 NCPDP: 570q`'n4 Phone: Signed Date: 01/15