Healthcare Provider Details

I. General information

NPI: 1528139458
Provider Name (Legal Business Name): SHIRA PORTNOY CRPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 MAIN ST LONG ISLAND FQHC, INC.
HEMPSTEAD NY
11550-2414
US

IV. Provider business mailing address

161 HEMPSTEAD TPKE LONG ISLAND FQHC, INC.
ELMONT NY
11003-1432
US

V. Phone/Fax

Practice location:
  • Phone: 516-571-8200
  • Fax:
Mailing address:
  • Phone: 516-571-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010450
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: