=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154513117
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHANNA PETRYCKI P.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2007
-----------------------------------------------------
Last Update Date | 10/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 MIDDLE COUNTRY RD SUITE 228
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-2871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-265-1351
-----------------------------------------------------
Fax | 631-265-9363
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 MIDDLE COUNTRY RD SUITE 228
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-2871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-265-1351
-----------------------------------------------------
Fax | 631-265-9363
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------