=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851459820
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY LYNN ENTIN PHYSICIAN ASST.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 10/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 79 GRAND AVE
-----------------------------------------------------
City | MASSAPEQUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-798-3376
-----------------------------------------------------
Fax | 516-798-5882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 CANDEE AVE
-----------------------------------------------------
City | SAYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11782-3059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-750-5575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 009989-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 009989-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------