Provider Demographics
NPI:1104356641
Name:CROTTY-O'GORMAN, JOAN TERESA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:TERESA
Last Name:CROTTY-O'GORMAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 TAMARACK DR
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL JCT
Mailing Address - State:NY
Mailing Address - Zip Code:12533-6428
Mailing Address - Country:US
Mailing Address - Phone:845-896-9331
Mailing Address - Fax:
Practice Address - Street 1:12 TAMARACK DR
Practice Address - Street 2:
Practice Address - City:HOPEWELL JCT
Practice Address - State:NY
Practice Address - Zip Code:12533-6428
Practice Address - Country:US
Practice Address - Phone:845-896-9331
Practice Address - Fax:845-896-9331
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331227363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily