Provider Demographics
NPI:1033647623
Name:PEGUERO-MEDRANO, ALEXANDER (NP)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:PEGUERO-MEDRANO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:MR
Other - First Name:ALEXANDER
Other - Middle Name:
Other - Last Name:PEGUERO-MEDRANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-632-9510
Mailing Address - Fax:631-632-5870
Practice Address - Street 1:169 PUTNAM HALL
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-3240
Practice Address - Country:US
Practice Address - Phone:631-632-9510
Practice Address - Fax:631-632-5870
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402196363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health