Provider Demographics
NPI:1720153570
Name:SUSSMAN, SCOTT EVAN (NP)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:EVAN
Last Name:SUSSMAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:325 MIDDLE COUNTRY ROAD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784
Mailing Address - Country:US
Mailing Address - Phone:631-732-4300
Mailing Address - Fax:631-732-4392
Practice Address - Street 1:325 MIDDLE COUNTRY ROAD
Practice Address - Street 2:SUITE 6
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784
Practice Address - Country:US
Practice Address - Phone:631-732-4300
Practice Address - Fax:631-732-4392
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334083363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ09139Medicare UPIN