Basic Information
| Provider Information | |||||||||
| NPI: | 1194258913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CERVINI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 290 N UTICA AVE | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117582148 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 FRANKLIN AVE STE ML2 | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115301760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166634400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2017 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F341564-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.