=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356079503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISA CASSARA ANP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2022
-----------------------------------------------------
Last Update Date | 08/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 ROUTE 25A
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-1348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-862-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1213 TOWNE HOUSE VLG
-----------------------------------------------------
City | ISLANDIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11749-4814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-554-4761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 310832
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------