Healthcare Provider Details

I. General information

NPI: 1962493668
Provider Name (Legal Business Name): JOSEPH REALE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 09/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HEALTHY WAY ATTN: PHYSICIAN BILLING DEPT
OCEANSIDE NY
11572-1551
US

IV. Provider business mailing address

12 ALFRED LANE
KINGS PARK NY
11754
US

V. Phone/Fax

Practice location:
  • Phone: 516-632-3000
  • Fax:
Mailing address:
  • Phone: 516-632-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number004677-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number004677
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: