Basic Information
| Provider Information | |||||||||
| NPI: | 1164428561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PLANTAMURA | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | ANPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROUTE 112 STE 101 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117768054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317510000 | ||||||||
| FaxNumber: | 6315096559 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 ROUTE 112 STE 101 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117768054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6315096559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F333425 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 02219538 | 05 | NY | MEDICAID |