Healthcare Provider Details

I. General information

NPI: 1114413770
Provider Name (Legal Business Name): SEAN MAHONEY NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2018
Last Update Date: 07/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 LAKEVILLE RD STE 107
NEW HYDE PARK NY
11042-1102
US

IV. Provider business mailing address

410 LAKEVILLE RD STE 107
NEW HYDE PARK NY
11042-1102
US

V. Phone/Fax

Practice location:
  • Phone: 516-465-5400
  • Fax:
Mailing address:
  • Phone: 516-465-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number342295
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: