Healthcare Provider Details

I. General information

NPI: 1629981311
Provider Name (Legal Business Name): EDWARD FERGUSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 SAXON AVE APT 3
BAY SHORE NY
11706-7030
US

IV. Provider business mailing address

20 SAXON AVE APT 3
BAY SHORE NY
11706-7030
US

V. Phone/Fax

Practice location:
  • Phone: 631-525-7397
  • Fax:
Mailing address:
  • Phone: 631-525-7397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number004520
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: