Healthcare Provider Details

I. General information

NPI: 1396808465
Provider Name (Legal Business Name): LOUISE ROSE CARDELLINA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 10/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 E MAIN ST
RIVERHEAD NY
11901-2675
US

IV. Provider business mailing address

PO BOX 1027
MATTITUCK NY
11952-0918
US

V. Phone/Fax

Practice location:
  • Phone: 631-603-3400
  • Fax:
Mailing address:
  • Phone: 631-298-1832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006286
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: