Provider Demographics
NPI:1407959430
Name:SUMMERS, JUDITH MARIE (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:MARIE
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:MISS
Other - First Name:JUDITH
Other - Middle Name:MARIE
Other - Last Name:ADANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:57 N. OCEANSIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570
Mailing Address - Country:US
Mailing Address - Phone:516-837-9864
Mailing Address - Fax:
Practice Address - Street 1:510 MONTAUK HIGHWAY
Practice Address - Street 2:SUITE C
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795
Practice Address - Country:US
Practice Address - Phone:631-587-1451
Practice Address - Fax:631-587-0503
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009084-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5294L1Medicare ID - Type Unspecified