Provider Demographics
NPI:1083663884
Name:MASTROPOLO, GREGG (CAA)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:
Last Name:MASTROPOLO
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S LITTLE TOR RD
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-3126
Mailing Address - Country:US
Mailing Address - Phone:706-888-2722
Mailing Address - Fax:845-230-7677
Practice Address - Street 1:900 23RD ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-2342
Practice Address - Country:US
Practice Address - Phone:202-823-4254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCA000014367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant