Basic Information
Provider Information | |||||||||
NPI: | 1578616785 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OMOYON-PERHAM | ||||||||
FirstName: | MARILOU | ||||||||
MiddleName: | MIRA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 272 | ||||||||
Address2: | ISLAND NEONATOLOGY PLLC | ||||||||
City: | EAST ISLIP | ||||||||
State: | NY | ||||||||
PostalCode: | 117300272 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6312241878 | ||||||||
FaxNumber: | 6312247963 | ||||||||
Practice Location | |||||||||
Address1: | 200 BELLE TERRE RD | ||||||||
Address2: | INTENSIVE CARE NURSERY | ||||||||
City: | PORT JEFFERSON | ||||||||
State: | NY | ||||||||
PostalCode: | 117771928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6314746577 | ||||||||
FaxNumber: | 6314746356 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | F350156-1 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
No ID Information.