=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770054710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEIDI FYRBERG PHYSICIAN ASSISTANT PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2018
-----------------------------------------------------
Last Update Date | 12/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1895 WALT WHITMAN RD
-----------------------------------------------------
City | MELVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11747-3031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-652-7100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 DONOVAN DR
-----------------------------------------------------
City | COLD SPRING HARBOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11724-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-652-7100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | HEIDI FYRBERG-COHEN
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 516-652-7100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------