Provider Demographics
NPI:1801567011
Name:MONANIAN, CHARLES AUSTIN
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:AUSTIN
Last Name:MONANIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:994 W JERICHO TPKE STE 104
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3211
Mailing Address - Country:US
Mailing Address - Phone:631-543-1440
Mailing Address - Fax:
Practice Address - Street 1:994 W JERICHO TPKE STE 104
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3211
Practice Address - Country:US
Practice Address - Phone:631-543-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029924363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA062949OtherPALS