Provider Demographics
NPI:1003474834
Name:MIRRO, JOSEPH E
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:E
Last Name:MIRRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 HUNTER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-1641
Mailing Address - Country:US
Mailing Address - Phone:631-278-9888
Mailing Address - Fax:
Practice Address - Street 1:518 HUNTER AVE
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-1641
Practice Address - Country:US
Practice Address - Phone:631-278-9888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024653363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant