Provider Demographics
NPI:1962171629
Name:IOTT, BALEIGH MARIE (PA)
Entity type:Individual
Prefix:
First Name:BALEIGH
Middle Name:MARIE
Last Name:IOTT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:31 SURREY DR
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-2821
Mailing Address - Country:US
Mailing Address - Phone:517-879-8915
Mailing Address - Fax:
Practice Address - Street 1:100 NICOLLS RD RM 80
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-2821
Practice Address - Country:US
Practice Address - Phone:631-444-1116
Practice Address - Fax:631-444-1535
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY027250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant