Provider Demographics
NPI:1285863654
Name:HALLERAN, GRACE LUCIA (PA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:LUCIA
Last Name:HALLERAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1129 NORTHERN BLVD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3022
Mailing Address - Country:US
Mailing Address - Phone:516-627-2121
Mailing Address - Fax:516-869-1386
Practice Address - Street 1:1129 NORTHERN BLVD
Practice Address - Street 2:SUITE 408
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3022
Practice Address - Country:US
Practice Address - Phone:516-627-2121
Practice Address - Fax:516-869-1386
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0132171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant