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W600000 Carrier ZYZ 2000 Hydra Road New York, NY 10001 Wolverine, Hugo 10 17 1960 2619 Avenue North Brooklyn NY NY 11235 555 5555555 111 1111111 G3000000 Wolverine^^^Hugo Y4 9900V13972 Carrier ZYZ Signature on File 01 02 2020 431 454 01 03 2020 01 03 2020 01 20 2020 0B 272222 DQ Charles Xavier, MD 1666699999 REFX5PA016182-8^^^G2PHYAS^^^PWK09EAC00985621^^^NTEADD20200302 0 M5020 0B 944444 01 20 20 01 20 20 11 99213 A 70 24 1 9877777777 211111110 WH002345 70 24 222 2222222 Charles Zavier, MD XMen Billing Services 490 Western Ave 200 Shore Drive Jean, Gray PA Brooklyn NY 11235 Great Neck NY 12345 01/20/2020 1666699999 1666699997 987-65-4321 XFactor Tactical Support 94 Jamaica Drive Jamaica 11422 EXAMPLE - PA SUPERVISED X

EXAMPLE - PA SUPERVISED W600000 Carrier ZYZ 2000 Hydra ... · Charles Zavier, MD XMen Billing Services 490 Western Ave 200 Shore Drive Jean, Gray PA Brooklyn NY 11235 Great Neck NY

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Page 1: EXAMPLE - PA SUPERVISED W600000 Carrier ZYZ 2000 Hydra ... · Charles Zavier, MD XMen Billing Services 490 Western Ave 200 Shore Drive Jean, Gray PA Brooklyn NY 11235 Great Neck NY

W600000Carrier ZYZ2000 Hydra RoadNew York, NY 10001

Wolverine, Hugo 10 17 1960

2619 Avenue North

Brooklyn NY NY

11235 555 5555555 111 1111111

G3000000

Wolverine^^^Hugo Y4 9900V13972

Carrier ZYZ

Signature on File

01 02 2020 431 454 01 03 2020 01 03 2020 01 20 20200B 272222

DQ Charles Xavier, MD 1666699999

REFX5PA016182-8^^^G2PHYAS^^^PWK09EAC00985621^^^NTEADD20200302

0M5020

0B 944444

01 20 20 01 20 20 11 99213 A 70 24 1 9877777777

211111110 WH002345 70 24222 2222222

Charles Zavier, MD XMen Billing Services490 Western Ave 200 Shore Drive

Jean, Gray PA Brooklyn NY 11235 Great Neck NY 1234501/20/2020 1666699999 1666699997

987-65-4321

XFactor Tactical Support

94 Jamaica Drive

Jamaica

11422

EXAMPLE - PA SUPERVISED

X

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1 NY 3 NEW YORK TRAINING 2010 NY NONRESIDENT RETURN IT 203 INSTR NY PUB 80 NY PUB 88

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