Basic Information
| Provider Information | |||||||||
| NPI: | 1578840393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENTHEROS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROUTE 112 BLDG 4 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117768055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6317510506 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 OLD COUNTRY RD BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6317510506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2011 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 310357 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 164W00000X | 306726-1 | NY | N | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.