Healthcare Provider Details

I. General information

NPI: 1164317871
Provider Name (Legal Business Name): JUAN SEBASTIAN LEMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 ISLIP AVE STE 27
ISLIP NY
11751-3226
US

IV. Provider business mailing address

148 ISLIP AVE STE 27
ISLIP NY
11751-3226
US

V. Phone/Fax

Practice location:
  • Phone: 631-650-6580
  • Fax: 631-650-6578
Mailing address:
  • Phone: 631-650-6580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number357080
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: