=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790957165
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE LEE ADAMS P.A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2008
-----------------------------------------------------
Last Update Date | 01/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 SUFFOLK AVE
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11717-4309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-231-4455
-----------------------------------------------------
Fax | 631-257-5098
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 SUFFOLK AVE
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11717-4309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-231-4455
-----------------------------------------------------
Fax | 631-257-5098
-----------------------------------------------------
=====================================================
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 | 012483
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------