Provider Demographics
NPI:1811550163
Name:SMALLEY, GREGORY W JR (NP)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
Last Name:SMALLEY
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6511 BOOTH ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4184
Mailing Address - Country:US
Mailing Address - Phone:718-806-1434
Mailing Address - Fax:
Practice Address - Street 1:6511 BOOTH ST APT 1C
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4184
Practice Address - Country:US
Practice Address - Phone:718-806-1434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF4314821363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care