Healthcare Provider Details

I. General information

NPI: 1528105095
Provider Name (Legal Business Name): JEANNINE R. SMITH P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PATRIOTS RD
STONY BROOK NY
11790-3318
US

IV. Provider business mailing address

100 PATRIOTS RD
STONY BROOK NY
11790-3318
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-8608
  • Fax: 631-444-8778
Mailing address:
  • Phone: 631-444-8608
  • Fax: 631-444-8778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003338-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: