Provider Demographics
NPI:1710268750
Name:DEPAULIS, PAUL ANTHONY
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTHONY
Last Name:DEPAULIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 SHIPS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-3928
Mailing Address - Country:US
Mailing Address - Phone:631-765-1124
Mailing Address - Fax:
Practice Address - Street 1:955 SHIPS DR
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-3928
Practice Address - Country:US
Practice Address - Phone:631-765-1124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-05
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249500-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse