Healthcare Provider Details

I. General information

NPI: 1861781619
Provider Name (Legal Business Name): PETER SPERICO NURSE PRACTITIONER IN F
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 GARDINER DRIVE PETER SPERICO NURSE PRACTITIONER IN FAMILY HEALTH PC
BAY SHORE NY
11706-6314
US

IV. Provider business mailing address

1056 GARDINER DRIVE PETER SPERICO NURSE PRACTITIONER IN FAMILY HEALTH PC
BAY SHORE NY
11706-6314
US

V. Phone/Fax

Practice location:
  • Phone: 516-455-3413
  • Fax: 631-969-0093
Mailing address:
  • Phone: 516-455-3413
  • Fax: 631-969-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number336101
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number409409
License Number StateNY

VIII. Authorized Official

Name: MR. PETER STEVEN SPERICO
Title or Position: PRESIDENT
Credential: FNP
Phone: 516-455-3413