Basic Information
| Provider Information | |||||||||
| NPI: | 1831868157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SLACK | ||||||||
| FirstName: | ANNELISE | ||||||||
| MiddleName: | PAIGE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | WEST BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117046435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313388379 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 PORT WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115761353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165626000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2021 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.