Healthcare Provider Details

I. General information

NPI: 1003326232
Provider Name (Legal Business Name): THERESA MARY CONWAY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COMMUNITY DR
MANHASSET NY
11030-3816
US

IV. Provider business mailing address

225 PARK AVE
WILLISTON PARK NY
11596-1133
US

V. Phone/Fax

Practice location:
  • Phone: 516-662-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number021260
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number021260
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: