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General NPI Number Information
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NPI Number | 1073931069
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Entity Type | Individual
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Provider Name | MS. FIZZAH IDREES
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Gender | Female
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Dates
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Enumeration Date | 04/07/2014
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Last Update Date | 12/03/2024
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Provider Practice Location Address
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Address Line | 1279 E MAIN ST
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City | RIVERHEAD
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State | NY
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Zip | 11901-2583
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Country | US
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Telephone | 631-727-2100
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Fax |
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Provider Business Mailing Address
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Address Line | 1279 E MAIN ST
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City | RIVERHEAD
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State | NY
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Zip | 11901-2583
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Country | US
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Telephone | 631-727-2100
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 017477
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License Number State | NY
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