Provider Demographics
NPI:1851459820
Name:ENTIN, STACY LYNN (PHYSICIAN ASST)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:ENTIN
Suffix:
Gender:F
Credentials:PHYSICIAN ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 CANDEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-3059
Mailing Address - Country:US
Mailing Address - Phone:631-750-5575
Mailing Address - Fax:
Practice Address - Street 1:79 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758
Practice Address - Country:US
Practice Address - Phone:516-798-3376
Practice Address - Fax:516-798-5882
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009989-1363A00000X
NY009989-01207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology