Healthcare Provider Details

I. General information

NPI: 1578220455
Provider Name (Legal Business Name): MATTHEW MERENSKY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2021
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SMITH HAVEN MALL STE 103
LAKE GROVE NY
11755-1219
US

IV. Provider business mailing address

4 SMITH HAVEN MALL STE 103
LAKE GROVE NY
11755-1219
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-4233
  • Fax: 631-444-4217
Mailing address:
  • Phone: 631-444-4233
  • Fax: 631-444-4217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number030424-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: