Provider Demographics
NPI:1376213132
Name:LOBASSO, SAMANTHA (MSN, RN, AGNP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LOBASSO
Suffix:
Gender:F
Credentials:MSN, RN, AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CENTRAL WOODS LN
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9712
Mailing Address - Country:US
Mailing Address - Phone:631-891-8954
Mailing Address - Fax:
Practice Address - Street 1:4 W 2ND ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2702
Practice Address - Country:US
Practice Address - Phone:631-548-6452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF310373-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner