Healthcare Provider Details

I. General information

NPI: 1942442223
Provider Name (Legal Business Name): SUPRANEE PROMBANTHOA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

IV. Provider business mailing address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

V. Phone/Fax

Practice location:
  • Phone: 516-572-6501
  • Fax: 516-572-5609
Mailing address:
  • Phone: 516-572-6501
  • Fax: 516-572-5609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012965
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: