Provider Demographics
NPI:1033143995
Name:PALERMO, JOHN (PHYSICAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PALERMO
Suffix:
Gender:M
Credentials:PHYSICAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:369 EAST MAIN STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2800
Mailing Address - Country:US
Mailing Address - Phone:631-581-4500
Mailing Address - Fax:631-581-1689
Practice Address - Street 1:55 NORTHERN BLVD
Practice Address - Street 2:STE 103
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4058
Practice Address - Country:US
Practice Address - Phone:516-466-9300
Practice Address - Fax:516-466-9353
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-07-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY006768363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYZH0WET0810OtherGROUP NUMBER
NY6195LET081Medicare ID - Type Unspecified
NYQ67913Medicare UPIN