Healthcare Provider Details

I. General information

NPI: 1770574246
Provider Name (Legal Business Name): ANDREW J RIBAUDO RPA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 WOODVILLE RD
SHOREHAM NY
11786-1331
US

IV. Provider business mailing address

185 OLD COUNTRY RD STE 2
RIVERHEAD NY
11901-2121
US

V. Phone/Fax

Practice location:
  • Phone: 631-929-1256
  • Fax: 631-929-8313
Mailing address:
  • Phone: 631-298-4479
  • Fax: 631-591-3047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: