Provider Demographics
NPI:1922759836
Name:O'LEARY, KRISTA
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 S WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4903
Mailing Address - Country:US
Mailing Address - Phone:631-225-2999
Mailing Address - Fax:
Practice Address - Street 1:290 S WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4903
Practice Address - Country:US
Practice Address - Phone:631-225-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant