Provider Demographics
NPI:1174630263
Name:NASTASI, JENNIFER ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:NASTASI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 HERMITAGE ST
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-9204
Mailing Address - Country:US
Mailing Address - Phone:631-929-8330
Mailing Address - Fax:
Practice Address - Street 1:2799 ROUTE 112 STE 11
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2535
Practice Address - Country:US
Practice Address - Phone:631-732-5222
Practice Address - Fax:631-732-6222
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228056208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02971039Medicaid
NYI22187Medicare UPIN