Provider Demographics
NPI:1528022381
Name:PROVETTO, THERESA A (PA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:PROVETTO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 E PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1915
Mailing Address - Country:US
Mailing Address - Phone:631-425-2145
Mailing Address - Fax:631-425-2296
Practice Address - Street 1:180 E PULASKI RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1915
Practice Address - Country:US
Practice Address - Phone:631-425-2145
Practice Address - Fax:631-425-2296
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002407363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02066017Medicaid
NY02066017Medicaid
NY0F5031Medicare PIN