Provider Demographics
NPI:1609817949
Name:KAPUR, SUSHMA (PA)
Entity Type:Individual
Prefix:
First Name:SUSHMA
Middle Name:
Last Name:KAPUR
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:631-638-4170
Practice Address - Street 1:100 NICOLLS RD # LEVEL4
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3407
Practice Address - Country:US
Practice Address - Phone:631-638-4170
Practice Address - Fax:631-638-4179
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P24020Medicare UPIN
NY1F9402Medicare ID - Type Unspecified