Healthcare Provider Details

I. General information

NPI: 1265321459
Provider Name (Legal Business Name): ANDREW OUTCAULT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HEROES WAY
RIVERHEAD NY
11901-2054
US

IV. Provider business mailing address

27 GREAT RIVER DR
SOUND BEACH NY
11789-2032
US

V. Phone/Fax

Practice location:
  • Phone: 631-548-6000
  • Fax:
Mailing address:
  • Phone: 631-365-7298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number719616
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: