Basic Information
| Provider Information | |||||||||
| NPI: | 1356855282 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOENIGSDORF | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 SENIX AVE | ||||||||
| Address2: | |||||||||
| City: | CENTER MORICHES | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119342902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317668931 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 ROANOKE AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315486000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2017 | ||||||||
| LastUpdateDate: | 11/30/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 021648 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.