Healthcare Provider Details

I. General information

NPI: 1528310224
Provider Name (Legal Business Name): LYNDSIE A WATKINS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2012
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ROANOKE AVENUE
RIVERHEAD NY
11901
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2478
  • Fax: 631-444-3919
Mailing address:
  • Phone: 631-444-0650
  • Fax: 631-638-4170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number015849
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: