Provider Demographics
NPI:1679833784
Name:BASSARAGH, CARMEN MILLICENT (ANP-C)
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:MILLICENT
Last Name:BASSARAGH
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2313
Mailing Address - Country:US
Mailing Address - Phone:631-941-1000
Mailing Address - Fax:
Practice Address - Street 1:421 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-2313
Practice Address - Country:US
Practice Address - Phone:631-941-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305792-364SA2200X
NY000575-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered