Provider Demographics
NPI:1508862079
Name:FRAGOLA, MARY ANN (ANPC)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:FRAGOLA
Suffix:
Gender:F
Credentials:ANPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 N BELLE MEAD RD
Mailing Address - Street 2:
Mailing Address - City:E SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3456
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:631-675-2001
Practice Address - Street 1:235 N BELLE MEAD RD
Practice Address - Street 2:
Practice Address - City:E SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3456
Practice Address - Country:US
Practice Address - Phone:631-751-3000
Practice Address - Fax:631-675-2001
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303023363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02242859Medicaid
NY02242859Medicaid
NY2E2031Medicare PIN