Provider Demographics
NPI:1386928265
Name:AUGUSTINE, JAIBY (ANP-C)
Entity type:Individual
Prefix:MR
First Name:JAIBY
Middle Name:
Last Name:AUGUSTINE
Suffix:
Gender:M
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 PALM ST
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2803
Mailing Address - Country:US
Mailing Address - Phone:631-946-6446
Mailing Address - Fax:
Practice Address - Street 1:286 SILLS RD
Practice Address - Street 2:SUITE 4
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-8810
Practice Address - Country:US
Practice Address - Phone:631-946-6446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY562539-1163W00000X
NYF305794-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse