Healthcare Provider Details

I. General information

NPI: 1275497216
Provider Name (Legal Business Name): JUSTIN BALSAMO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 S BAY AVE
ISLIP NY
11751-4411
US

IV. Provider business mailing address

118 S BAY AVE
ISLIP NY
11751-4411
US

V. Phone/Fax

Practice location:
  • Phone: 631-383-0665
  • Fax:
Mailing address:
  • Phone: 631-383-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number954110205
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number883212-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: