Provider Demographics
NPI:1467418723
Name:DECONZA, SANDRA E (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:E
Last Name:DECONZA
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BABCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6705
Mailing Address - Country:US
Mailing Address - Phone:631-676-6091
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4870
Practice Address - Country:US
Practice Address - Phone:631-654-7195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010356363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical