=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164375333
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN CARLOS SERNA RN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2026
-----------------------------------------------------
Last Update Date | 02/18/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 LUBBER ST
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-903-3520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 LUBBER ST
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-903-3520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 451213
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------