Provider Demographics
NPI:1215462205
Name:GOTTLIEB, MICHAEL S (FNP-BC(ANCC) MSN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:FNP-BC(ANCC) MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PECONIC ST
Mailing Address - Street 2:92A
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7100
Mailing Address - Country:US
Mailing Address - Phone:929-430-7907
Mailing Address - Fax:
Practice Address - Street 1:500 PECONIC ST
Practice Address - Street 2:92A
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7100
Practice Address - Country:US
Practice Address - Phone:631-833-0696
Practice Address - Fax:206-350-1094
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF-341691363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner