Basic Information
| Provider Information | |||||||||
| NPI: | 1174630263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NASTASI | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 HERMITAGE ST | ||||||||
| Address2: | |||||||||
| City: | WADING RIVER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117929204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319298330 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2799 ROUTE 112 STE 11 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117632535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317325222 | ||||||||
| FaxNumber: | 6317326222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 09/27/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 228056 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02971039 | 05 | NY | MEDICAID |