Provider Demographics
NPI:1659188696
Name:SHAY, SAMANTHA ROSE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:SHAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-1937
Mailing Address - Country:US
Mailing Address - Phone:631-678-2568
Mailing Address - Fax:
Practice Address - Street 1:300 E MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2900
Practice Address - Country:US
Practice Address - Phone:631-780-6128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF352267-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily