Provider Demographics
NPI:1336341023
Name:NAIDU, PREETHI K (PA)
Entity Type:Individual
Prefix:MS
First Name:PREETHI
Middle Name:K
Last Name:NAIDU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:PREETHI
Other - Middle Name:K
Other - Last Name:NAIDU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:3505 VETERANS MEMORIAL HWY STE C
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7613
Mailing Address - Country:US
Mailing Address - Phone:631-676-7656
Mailing Address - Fax:631-676-7648
Practice Address - Street 1:3505 VETERANS MEMORIAL HWY STE C
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7613
Practice Address - Country:US
Practice Address - Phone:631-676-7656
Practice Address - Fax:631-676-7648
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011094363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid