Provider Demographics
NPI:1265863245
Name:PJS PROFESSIONAL NURSE PRACTITIONER IN ADULT HEALTH PLLC
Entity type:Organization
Organization Name:PJS PROFESSIONAL NURSE PRACTITIONER IN ADULT HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:EHRMAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:ANP-C
Authorized Official - Phone:631-790-1239
Mailing Address - Street 1:22 MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3012
Mailing Address - Country:US
Mailing Address - Phone:631-790-1239
Mailing Address - Fax:
Practice Address - Street 1:22 MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3012
Practice Address - Country:US
Practice Address - Phone:631-790-1239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304949314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03075505Medicaid
NYA300033305Medicare PIN