Healthcare Provider Details

I. General information

NPI: 1407766256
Provider Name (Legal Business Name): EMILY TIRADO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONTAUK HWY
WEST ISLIP NY
11795-4927
US

IV. Provider business mailing address

18 PALM ST
SELDEN NY
11784-2804
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-3000
  • Fax:
Mailing address:
  • Phone: 631-987-0687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: