Provider Demographics
NPI:1063013415
Name:CACCIOTTI, CARL MARK (AGNP-BC)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:MARK
Last Name:CACCIOTTI
Suffix:
Gender:M
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 SWEETMILK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-9100
Mailing Address - Country:US
Mailing Address - Phone:518-330-3396
Mailing Address - Fax:
Practice Address - Street 1:81 SWEETMILK CREEK RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-9100
Practice Address - Country:US
Practice Address - Phone:518-330-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309865363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology