Provider Demographics
NPI:1730604752
Name:IPPOLITO, DANIEL THOMAS (ANP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:THOMAS
Last Name:IPPOLITO
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3620
Mailing Address - Country:US
Mailing Address - Phone:631-666-3951
Mailing Address - Fax:631-750-1177
Practice Address - Street 1:77 MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1281
Practice Address - Country:US
Practice Address - Phone:631-666-3951
Practice Address - Fax:631-750-1177
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308385363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY308385OtherNYS OFFICE OF PROFESSIONS