Healthcare Provider Details

I. General information

NPI: 1255334363
Provider Name (Legal Business Name): KAREN RENATE DYBUS RPA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STUDENT HEALTH SERVICE STADIUM ROAD
STONY BROOK NY
11794-3191
US

IV. Provider business mailing address

10 TODD CT
SOUTH HUNTINGTON NY
11746-4224
US

V. Phone/Fax

Practice location:
  • Phone: 631-632-6739
  • Fax: 631-632-6936
Mailing address:
  • Phone: 631-470-3243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4005-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: