Provider Demographics
NPI:1942311360
Name:RONGO, JOHN (MS-PAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RONGO
Suffix:
Gender:M
Credentials:MS-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 TECHNOLOGY DR STE 11
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3464
Mailing Address - Country:US
Mailing Address - Phone:631-298-4579
Mailing Address - Fax:631-298-4852
Practice Address - Street 1:14 TECHNOLOGY DR STE 11
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3464
Practice Address - Country:US
Practice Address - Phone:631-298-4579
Practice Address - Fax:631-298-4852
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0071531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
5669L1Medicare ID - Type Unspecified
P27170Medicare UPIN