Most Relevant Information
Provider Data
| NPI Number: | 1003440504 |
| Provider Name: | NICOLAS MAVROMOUSTAKOS |
| Entity Type: | Individual |
| Taxonomy Code: | 363A00000X |
| Specialty: | Physician Assistant |
| License Number: | 026722 |
Most Important Dates
| Enumeration Date: | 02/24/2020 |
| Last Updated: | 07/15/2021 |
Provider Practice Location
14 BIRCH AVE
HUNTINGTON
NY
117434655
Practice Location Phone/Fax
| Phone: | 6316625714 |
| Fax: |
Provider Mailing Location
14 BIRCH AVE
HUNTINGTON
NY
117434655
Provider Mailing Phone/Fax
| Phone: | |
| Fax: |