Healthcare Provider Details

I. General information

NPI: 1972544260
Provider Name (Legal Business Name): MARIA JUVAN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 TECHNOLOGY DR
E SETAUKET NY
11733-3472
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-4233
  • Fax:
Mailing address:
  • Phone: 631-444-4233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007452
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: