Provider Demographics
NPI:1336223445
Name:NOMBERG, ANDREA E (MD)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:E
Last Name:NOMBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 HAWKINS AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2293
Mailing Address - Country:US
Mailing Address - Phone:631-588-0880
Mailing Address - Fax:631-588-0391
Practice Address - Street 1:709 HAWKINS AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2293
Practice Address - Country:US
Practice Address - Phone:631-588-0880
Practice Address - Fax:631-588-0391
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G42611Medicare UPIN
NY464961Medicare ID - Type Unspecified