Provider Demographics
NPI:1093089542
Name:PONTINO, TERRY (NP)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:PONTINO
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 1:475 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3121
Mailing Address - Country:US
Mailing Address - Phone:631-475-7700
Mailing Address - Fax:631-307-9911
Practice Address - Street 1:475 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-475-7700
Practice Address - Fax:631-307-9911
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY431103363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care