Provider Demographics
NPI:1114009115
Name:DECOLLIBUS, DAMIEN ANTHONY (PA)
Entity Type:Individual
Prefix:MR
First Name:DAMIEN
Middle Name:ANTHONY
Last Name:DECOLLIBUS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 E 77TH ST
Mailing Address - Street 2:DIVISION OF VASCULAR SURGERY
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1850
Mailing Address - Country:US
Mailing Address - Phone:212-434-4264
Mailing Address - Fax:212-434-4231
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:DIVISION OF VASCULAR SURGERY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1850
Practice Address - Country:US
Practice Address - Phone:212-434-4264
Practice Address - Fax:212-434-4231
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY010067363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00330231Medicare ID - Type Unspecified