Basic Information
Provider Information | |||||||||
NPI: | 1780153072 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ONUFRAK | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VASTA | ||||||||
OtherFirstName: | CYNTHIA | ||||||||
OtherMiddleName: | J. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1559 | ||||||||
Address2: |   | ||||||||
City: | STONY BROOK | ||||||||
State: | NY | ||||||||
PostalCode: | 117900989 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6314442599 | ||||||||
FaxNumber: | 6314441474 | ||||||||
Practice Location | |||||||||
Address1: | 181 N BELLE MEAD RD | ||||||||
Address2: |   | ||||||||
City: | EAST SETAUKET | ||||||||
State: | NY | ||||||||
PostalCode: | 117333495 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6314442599 | ||||||||
FaxNumber: | 6314441474 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2018 | ||||||||
LastUpdateDate: | 04/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 308827 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.