Provider Demographics
NPI:1033465133
Name:LARICCIA, NATHAN A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:A
Last Name:LARICCIA
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 1:401 PICTURESQUE DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-1005
Mailing Address - Country:US
Mailing Address - Phone:585-472-4387
Mailing Address - Fax:
Practice Address - Street 1:ELM AND CARLTON STREETS
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263-2733
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015563-1363A00000X, 363AM0700X
NY15563363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant