MEDICARE: SARAH ANGELA VAN BRUNT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	021649	NY

General Provider Information

NPI Number	:	1073026217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH ANGELA VAN BRUNT

Provider Business Mailing Address
First Line	:	205 BAYVIEW AVE
Second Line	:
City	:	BAYPORT
State	:	NY
Zip	:	11705-2157
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 N BROADWAY
Second Line	:
City	:	JERICHO
State	:	NY
Zip	:	11753-2134
Country	:	US
Telephone Number	:	516-597-5070
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2017
Last Update Date	:	12/12/2022

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Directions to “ SARAH ANGELA VAN BRUNT ” Practice Location

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