Provider Demographics
NPI:1043304884
Name:MOZZILLO, CRAIG MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:MICHAEL
Last Name:MOZZILLO
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 1:506 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3609
Mailing Address - Country:US
Mailing Address - Phone:718-780-5040
Mailing Address - Fax:718-780-7805
Practice Address - Street 1:506 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3609
Practice Address - Country:US
Practice Address - Phone:718-780-5040
Practice Address - Fax:718-780-7805
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5F2931Medicaid
NY5F2931Medicaid
P000137411Medicare PIN