Basic Information
| Provider Information | |||||||||
| NPI: | 1851459820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENTIN | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PHYSICIAN ASST. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 CANDEE AVE | ||||||||
| Address2: | |||||||||
| City: | SAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117823059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317505575 | ||||||||
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| Practice Location | |||||||||
| Address1: | 79 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167983376 | ||||||||
| FaxNumber: | 5167985882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 10/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 009989-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207VG0400X | 009989-01 | NY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
No ID Information.