Basic Information
| Provider Information | |||||||||
| NPI: | 1184162620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALTAZAR | ||||||||
| FirstName: | SHERYLL ANN | ||||||||
| MiddleName: | POLLO | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 BERKELEY AVE | ||||||||
| Address2: | |||||||||
| City: | SELDEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117841904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315123623 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 181 N BELLE MEAD RD | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117333495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314442599 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2017 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 307950 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.