Provider Demographics
NPI:1932817533
Name:PROACTIVE ADULT HEALTH NP, P.C.
Entity Type:Organization
Organization Name:PROACTIVE ADULT HEALTH NP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:DUPERVAL
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:516-915-9771
Mailing Address - Street 1:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-0292
Mailing Address - Country:US
Mailing Address - Phone:516-915-9771
Mailing Address - Fax:
Practice Address - Street 1:17 LINMOUTH RD
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565-2202
Practice Address - Country:US
Practice Address - Phone:516-915-9771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty