Healthcare Provider Details

I. General information

NPI: 1154477180
Provider Name (Legal Business Name): MARY LYNN STRAW ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL RD
PATCHOGUE NY
11772-4870
US

IV. Provider business mailing address

270 BRIDGEPORT AVE
MEDFORD NY
11763-4019
US

V. Phone/Fax

Practice location:
  • Phone: 631-687-4175
  • Fax:
Mailing address:
  • Phone: 631-687-4175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number30303058
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: