Healthcare Provider Details

I. General information

NPI: 1750276457
Provider Name (Legal Business Name): PAUL JOSEPH MALLIA MS, MBA, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 MONTAUK HWY STE 1
OAKDALE NY
11769-1801
US

IV. Provider business mailing address

1 CAMPUS DR
EAST SETAUKET NY
11733-1103
US

V. Phone/Fax

Practice location:
  • Phone: 631-739-4210
  • Fax:
Mailing address:
  • Phone: 631-739-4210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number357071
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number798704
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: