Provider Demographics
NPI:1578220455
Name:MERENSKY, MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MERENSKY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SMITH HAVEN MALL STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1219
Mailing Address - Country:US
Mailing Address - Phone:631-444-4233
Mailing Address - Fax:631-444-4217
Practice Address - Street 1:4 SMITH HAVEN MALL STE 103
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1219
Practice Address - Country:US
Practice Address - Phone:631-444-4233
Practice Address - Fax:631-444-4217
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-26
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030424-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant