Provider Demographics
NPI:1275980104
Name:MCKENNA, PETER
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STONY BROOK MEDICINE DEPARTMENT OF EMERGENCY
Mailing Address - Street 2:HSC LEVEL 4 ROOM 080
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8350
Mailing Address - Country:US
Mailing Address - Phone:631-444-3880
Mailing Address - Fax:631-444-3919
Practice Address - Street 1:STONY BROOK MEDICINE DEPARTMENT OF EMERGENCY
Practice Address - Street 2:HSC LEVEL 4 ROOM 080
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8350
Practice Address - Country:US
Practice Address - Phone:631-444-3880
Practice Address - Fax:631-444-3919
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297011207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine