Provider Demographics
NPI:1497591507
Name:PECONIC BAY FACULTY MEDICAL AFFILIATES, UNIVERSITY FACULTY PRACTICE CO
Entity type:Organization
Organization Name:PECONIC BAY FACULTY MEDICAL AFFILIATES, UNIVERSITY FACULTY PRACTICE CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTICIONER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:631-548-6063
Mailing Address - Street 1:1 HEROES WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2054
Mailing Address - Country:US
Mailing Address - Phone:631-548-6063
Mailing Address - Fax:631-548-6007
Practice Address - Street 1:1 HEROES WAY
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2054
Practice Address - Country:US
Practice Address - Phone:631-548-6063
Practice Address - Fax:631-548-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty