Provider Demographics
NPI:1932330677
Name:DAGROSA-MANSO, PAULA (ANP)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:DAGROSA-MANSO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HEATH CT
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2316
Mailing Address - Country:US
Mailing Address - Phone:631-751-2855
Mailing Address - Fax:
Practice Address - Street 1:400 HORSEBLOCK RD
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738
Practice Address - Country:US
Practice Address - Phone:631-451-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304984-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner