Provider Demographics
NPI:1205488970
Name:BAUMGARTNER, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BAUMGARTNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 RONKONKOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3314
Mailing Address - Country:US
Mailing Address - Phone:631-655-6484
Mailing Address - Fax:
Practice Address - Street 1:122 RONKONKOMA BLVD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3314
Practice Address - Country:US
Practice Address - Phone:631-655-6484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024218363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty