MEDICARE: MR. JUSTIN BALSAMO RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	954110205	CA
2	163W00000X	Registered Nurse	883212-01	NY

General Provider Information

NPI Number	:	1275497216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN BALSAMO RN

Provider Business Mailing Address
First Line	:	118 S BAY AVE
Second Line	:
City	:	ISLIP
State	:	NY
Zip	:	11751-4411
Country	:	US
Telephone Number	:	631-383-0665
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 S BAY AVE
Second Line	:
City	:	ISLIP
State	:	NY
Zip	:	11751-4411
Country	:	US
Telephone Number	:	631-383-0665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2025
Last Update Date	:	12/15/2025

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