Provider Demographics
NPI:1083040075
Name:BAS, MARICON (NP)
Entity Type:Individual
Prefix:
First Name:MARICON
Middle Name:
Last Name:BAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 7TH AVE N
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2208
Mailing Address - Country:US
Mailing Address - Phone:631-470-5962
Mailing Address - Fax:
Practice Address - Street 1:3500 SUNRISE HWY STE 124
Practice Address - Street 2:
Practice Address - City:GREAT RIVER
Practice Address - State:NY
Practice Address - Zip Code:11739-1001
Practice Address - Country:US
Practice Address - Phone:631-854-0365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY643137163W00000X
NY309238363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse