Healthcare Provider Details

I. General information

NPI: 1538094925
Provider Name (Legal Business Name): UNBRIDLED AESTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 HIDDEN POND PATH
WADING RIVER NY
11792-2184
US

IV. Provider business mailing address

245 HIDDEN POND PATH
WADING RIVER NY
11792-2184
US

V. Phone/Fax

Practice location:
  • Phone: 631-662-0614
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ERICA MCBRIDE
Title or Position: PHYSICIAN ASSISTANT
Credential:
Phone: 631-662-0614