Provider Demographics
NPI:1598501694
Name:LONG ISLAND JEWISH FACULTY MEDICAL AFFILIATES, UNIVERSITY FACULTY PRAC
Entity type:Organization
Organization Name:LONG ISLAND JEWISH FACULTY MEDICAL AFFILIATES, UNIVERSITY FACULTY PRAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AFONSO
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:718-470-7000
Mailing Address - Street 1:27005 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1402
Mailing Address - Country:US
Mailing Address - Phone:718-470-7000
Mailing Address - Fax:718-962-6759
Practice Address - Street 1:27005 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1402
Practice Address - Country:US
Practice Address - Phone:718-470-7000
Practice Address - Fax:718-962-6759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty