Healthcare Provider Details

I. General information

NPI: 1962667469
Provider Name (Legal Business Name): ROSE M BUKOVSKY ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 NESCONSET HWY SUITE 1
PORT JEFFERSON STATION NY
11776-2053
US

IV. Provider business mailing address

5225 NESCONSET HWY SUITE 1
PORT JEFFERSON STATION NY
11776-2053
US

V. Phone/Fax

Practice location:
  • Phone: 631-406-6776
  • Fax:
Mailing address:
  • Phone: 631-406-6776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF304902
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: