Provider Demographics
NPI:1003034141
Name:SELVAGGI, KRISTY (RPAC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:
Last Name:SELVAGGI
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:MS
Other - First Name:KRISTY
Other - Middle Name:
Other - Last Name:HELIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPAC
Mailing Address - Street 1:23 ACORN LANE
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790
Mailing Address - Country:US
Mailing Address - Phone:631-807-2568
Mailing Address - Fax:
Practice Address - Street 1:1000 MONTAUK HIGHWAY
Practice Address - Street 2:GOOD SAMARITAN HOSPITAL
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795
Practice Address - Country:US
Practice Address - Phone:631-376-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant