Provider Demographics
NPI:1164440392
Name:CERASOLI, MARCO J (PA-C)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:J
Last Name:CERASOLI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HYGEIA DRIVE
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 GLASGOW AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-4773
Practice Address - Country:US
Practice Address - Phone:302-836-8350
Practice Address - Fax:302-836-8359
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000211363AM0700X
DEC5-0000211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEP42779Medicare UPIN