Provider Demographics
NPI:1780944363
Name:PROBECK, KRISTAN (RN, MS, ANP)
Entity type:Individual
Prefix:MS
First Name:KRISTAN
Middle Name:
Last Name:PROBECK
Suffix:
Gender:F
Credentials:RN, MS, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NICHOLLS RD
Mailing Address - Street 2:HSC 19-090 DEPARTMENT OF VASCULAR SURGERY
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-444-5454
Mailing Address - Fax:
Practice Address - Street 1:1743 NORTH OCEAN AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763
Practice Address - Country:US
Practice Address - Phone:631-758-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY544021163W00000X
NY30 305525363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse