Healthcare Provider Details

I. General information

NPI: 1063510394
Provider Name (Legal Business Name): JOHN A BEATTIE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL RD
PATCHOGUE NY
11772-4870
US

IV. Provider business mailing address

8 PINEHURST CT
SELDEN NY
11784-3223
US

V. Phone/Fax

Practice location:
  • Phone: 631-687-4179
  • Fax:
Mailing address:
  • Phone: 631-698-2678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number001222-1
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: