Healthcare Provider Details

I. General information

NPI: 1487087342
Provider Name (Legal Business Name): MRS. ANDREA GEWANTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1927 JULIAN LN
MERRICK NY
11566-5201
US

IV. Provider business mailing address

1927 JULIAN LN
MERRICK NY
11566-5201
US

V. Phone/Fax

Practice location:
  • Phone: 631-431-3103
  • Fax:
Mailing address:
  • Phone: 631-431-4310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1841962
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: