Provider Demographics
NPI:1962411181
Name:MANCUSO, GLORIA KAY (OG NP)
Entity type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:KAY
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:OG NP
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:365 EAST MAIN ST
Mailing Address - Street 2:SOUTH BROOKHAVEN HEALTH CENTER WEST
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-854-1307
Mailing Address - Fax:631-854-1310
Practice Address - Street 1:365 EAST MAIN ST
Practice Address - Street 2:SOUTH BROOKHAVEN HEALTH CENTER WEST
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-854-1307
Practice Address - Fax:631-854-1310
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF390002363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
S71671Medicare UPIN
NY09V061Medicare ID - Type Unspecified