Provider Demographics
NPI:1205199866
Name:SIRAGUSA, MARIA (MS)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:SIRAGUSA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CARLISLE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1018
Mailing Address - Country:US
Mailing Address - Phone:631-754-2996
Mailing Address - Fax:
Practice Address - Street 1:55 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803
Practice Address - Country:US
Practice Address - Phone:516-576-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY873445174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist