Basic Information
| Provider Information | |||||||||
| NPI: | 1669462370 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUNDBERG | ||||||||
| FirstName: | MICHELINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 951 ROANOKE AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313695005 | ||||||||
| FaxNumber: | 6313694994 | ||||||||
| Practice Location | |||||||||
| Address1: | 951 ROANOKE AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313695005 | ||||||||
| FaxNumber: | 6313694994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 008222 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 02519753 | 05 | NY | MEDICAID |