Provider Demographics
NPI:1356301428
Name:FLANAGAN-KUNDLE, MARY G (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:FLANAGAN-KUNDLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2583
Mailing Address - Country:US
Mailing Address - Phone:631-284-3793
Mailing Address - Fax:631-591-3900
Practice Address - Street 1:329 E MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2821
Practice Address - Country:US
Practice Address - Phone:631-265-1855
Practice Address - Fax:631-724-2579
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001163363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001163OtherLICENSE
NY001163OtherLICENSE