Healthcare Provider Details

I. General information

NPI: 1386103802
Provider Name (Legal Business Name): MARIA KASDAN NURSE PRACTITIONER OF PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 N OCEAN AVE
PATCHOGUE NY
11772-2004
US

IV. Provider business mailing address

47 GLENMERE LN
CORAM NY
11727-1428
US

V. Phone/Fax

Practice location:
  • Phone: 631-512-9260
  • Fax: 631-588-8901
Mailing address:
  • Phone: 631-838-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MARIA ANNE KASDAN
Title or Position: OWNER/PRACTITIONER
Credential: NP
Phone: 631-838-4300