Healthcare Provider Details

I. General information

NPI: 1528009206
Provider Name (Legal Business Name): DASHURIJE RUPOLO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL ROAD MEDICAL CENTER
PATCHOGUE NY
11772
US

IV. Provider business mailing address

60 ROBINSON AVE
EAST PATCHOGUE NY
11772-4842
US

V. Phone/Fax

Practice location:
  • Phone: 631-687-2953
  • Fax: 610-617-6280
Mailing address:
  • Phone: 917-519-2102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0090121
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: