Provider Demographics
NPI:1083653299
Name:PIETROMICCA, CHERYL (PA)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:PIETROMICCA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 MONARCH DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1523
Mailing Address - Country:US
Mailing Address - Phone:716-867-6381
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-4803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00026762101OtherEXCELLUS UNIVERA
NY000527486006OtherHEALTH NOW
NY9512451OtherINDEPENDENT HEALTH
NY9512451OtherINDEPENDENT HEALTH
NYPA0199Medicare PIN