Provider Demographics
NPI:1578840393
Name:PENTHEROS, STEPHEN ANDREW (NP)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ANDREW
Last Name:PENTHEROS
Suffix:
Gender:M
Credentials:NP
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Other - First Name:
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Other - Last Name:
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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:631-751-3000
Mailing Address - Fax:631-751-0506
Practice Address - Street 1:750 OLD COUNTRY RD BLDG 2
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2153
Practice Address - Country:US
Practice Address - Phone:631-751-3000
Practice Address - Fax:631-751-0506
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2021-10-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY310357363LA2200X
NY306726-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse