Provider Demographics
NPI:1619259942
Name:AVERSO, SUSAN M (PNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:AVERSO
Suffix:
Gender:F
Credentials:PNP
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 12
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-0012
Mailing Address - Country:US
Mailing Address - Phone:631-924-1000
Mailing Address - Fax:631-924-1243
Practice Address - Street 1:35 LONGWOOD RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2045
Practice Address - Country:US
Practice Address - Phone:631-924-1000
Practice Address - Fax:631-924-1243
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381569-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics