Provider Demographics
NPI:1982701603
Name:PEREZ, JOSE L (PA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:PEREZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 RTE 25A
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1348
Mailing Address - Country:US
Mailing Address - Phone:631-862-3000
Mailing Address - Fax:631-862-3105
Practice Address - Street 1:50 RTE 25A
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1348
Practice Address - Country:US
Practice Address - Phone:631-862-3000
Practice Address - Fax:631-862-3105
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5781043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS56967Medicare UPIN
NYZ8887X0281Medicare PIN