Healthcare Provider Details

I. General information

NPI: 1417076084
Provider Name (Legal Business Name): SUZANNE MARY FLYNN RPAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUSTAVE L LEVY PLACE BOX 1104
NEW YORK NY
10029
US

IV. Provider business mailing address

137 SOUTHDOWN RD
HUNTINGTON NY
11743-2544
US

V. Phone/Fax

Practice location:
  • Phone: 631-834-5237
  • Fax:
Mailing address:
  • Phone: 631-673-9175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011659-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: