Provider Demographics
NPI:1063987428
Name:GLOVER, JUDYTA
Entity type:Individual
Prefix:
First Name:JUDYTA
Middle Name:
Last Name:GLOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2204
Mailing Address - Country:US
Mailing Address - Phone:631-766-0963
Mailing Address - Fax:
Practice Address - Street 1:100 MERRICK RD STE 128W
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4821
Practice Address - Country:US
Practice Address - Phone:516-225-9031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1158649Medicaid