Provider Demographics
NPI:1568614733
Name:SACCARO, SHAYNA MADELEINE (NP)
Entity Type:Individual
Prefix:
First Name:SHAYNA
Middle Name:MADELEINE
Last Name:SACCARO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112 BLDG 4
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-751-0000
Mailing Address - Fax:631-751-0506
Practice Address - Street 1:6144 ROUTE 25A STE 19
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2015
Practice Address - Country:US
Practice Address - Phone:631-751-0000
Practice Address - Fax:631-751-0506
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-18
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294869164W00000X
NY346025363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty