Provider Demographics
NPI:1629259668
Name:NUCCI, STEPHANIE II (PA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:NUCCI
Suffix:II
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:635 BELLE TERRE RD
Mailing Address - Street 2:SUITE #204
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1935
Mailing Address - Country:US
Mailing Address - Phone:631-474-0008
Mailing Address - Fax:631-474-0224
Practice Address - Street 1:635 BELLE TERRE RD
Practice Address - Street 2:SUITE #204
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1935
Practice Address - Country:US
Practice Address - Phone:631-474-0008
Practice Address - Fax:631-474-0224
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY009608363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ19473Medicare UPIN
NY1629259668Medicare PIN