Provider Demographics
NPI:1669462370
Name:SUNDBERG, MICHELINA (PA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELINA
Middle Name:
Last Name:SUNDBERG
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 1:951 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2724
Mailing Address - Country:US
Mailing Address - Phone:631-369-5005
Mailing Address - Fax:631-369-4994
Practice Address - Street 1:951 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2724
Practice Address - Country:US
Practice Address - Phone:631-369-5005
Practice Address - Fax:631-369-4994
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008222363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02519753Medicaid
NY4F9191Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NY02519753Medicaid