Provider Demographics
NPI:1992723167
Name:DELANEY, DOREEN (PA)
Entity type:Individual
Prefix:MS
First Name:DOREEN
Middle Name:
Last Name:DELANEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 HALLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2048
Mailing Address - Country:US
Mailing Address - Phone:631-476-9100
Mailing Address - Fax:631-476-4919
Practice Address - Street 1:1110 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2048
Practice Address - Country:US
Practice Address - Phone:631-476-9100
Practice Address - Fax:631-476-4919
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0062761363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05749940Medicaid
5F0581Medicare ID - Type Unspecified