Provider Demographics
NPI:1962493668
Name:REALE, JOSEPH (PA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:REALE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ALFRED LANE
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754
Mailing Address - Country:US
Mailing Address - Phone:516-632-3000
Mailing Address - Fax:
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:ATTN: PHYSICIAN BILLING DEPT
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1551
Practice Address - Country:US
Practice Address - Phone:516-632-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004677-1363AS0400X
NY004677363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS62211Medicare UPIN
NY0F0611Medicare PIN