Provider Demographics
NPI:1063869683
Name:TESORIERO, DEBRA (NP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:TESORIERO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 E WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1423
Mailing Address - Country:US
Mailing Address - Phone:631-758-6565
Mailing Address - Fax:631-758-6568
Practice Address - Street 1:155 E WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1423
Practice Address - Country:US
Practice Address - Phone:631-758-6565
Practice Address - Fax:631-758-6568
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF382507363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics