Provider Demographics
NPI:1093805830
Name:CIESLA, COURTNEY A (PA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:A
Last Name:CIESLA
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:PO BOX 826223
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-6223
Mailing Address - Country:US
Mailing Address - Phone:616-464-0027
Mailing Address - Fax:770-237-1723
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1551
Practice Address - Country:US
Practice Address - Phone:516-632-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011274-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02848460Medicaid
Q73390Medicare UPIN
NY02848460Medicaid
NYP00360615Medicare PIN
NY6746L1Medicare PIN
P00416588Medicare PIN