Provider Demographics
NPI:1306812052
Name:OLIVERI, MICHAEL P (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:OLIVERI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 RESEARCH WAY STE 108
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-6401
Mailing Address - Country:US
Mailing Address - Phone:631-941-2000
Mailing Address - Fax:
Practice Address - Street 1:45 RESEARCH WAY STE 108
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-6401
Practice Address - Country:US
Practice Address - Phone:631-473-1320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009092-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5205L1Medicare ID - Type Unspecified
Q05674Medicare UPIN