Provider Demographics
NPI:1619679180
Name:SHERIDAN, BRIAN JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:SHERIDAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2636
Mailing Address - Country:US
Mailing Address - Phone:516-582-6641
Mailing Address - Fax:
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1353
Practice Address - Country:US
Practice Address - Phone:516-562-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant