Provider Demographics
NPI:1285374660
Name:VALDEMAR, REGGIE DONALD (PHMNP)
Entity type:Individual
Prefix:
First Name:REGGIE
Middle Name:DONALD
Last Name:VALDEMAR
Suffix:
Gender:M
Credentials:PHMNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 OAK PARK CT
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5607
Mailing Address - Country:US
Mailing Address - Phone:631-565-3480
Mailing Address - Fax:
Practice Address - Street 1:153 LAKE SHORE RD
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-3157
Practice Address - Country:US
Practice Address - Phone:111-111-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404034363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health