Provider Demographics
NPI:1093953838
Name:CIANCIABELLA, AUGUSTO JORGE (PA)
Entity Type:Individual
Prefix:
First Name:AUGUSTO
Middle Name:JORGE
Last Name:CIANCIABELLA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10502 PARK RD STE 120
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8490
Mailing Address - Country:US
Mailing Address - Phone:704-702-3880
Mailing Address - Fax:
Practice Address - Street 1:10502 PARK RD STE 120
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8490
Practice Address - Country:US
Practice Address - Phone:704-702-3880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AS0400X
CAPA20179363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9105911OtherLICENSE
FLY06SSOtherBCBS FL
CAPA20179OtherCALIFORNIA LICENSE
FLET529ZMedicare PIN