Provider Demographics
NPI:1164933149
Name:PICCOLO, ANTHONY J (PA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:PICCOLO
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 1:197 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-2702
Mailing Address - Country:US
Mailing Address - Phone:973-857-0330
Mailing Address - Fax:973-857-0980
Practice Address - Street 1:197 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-2702
Practice Address - Country:US
Practice Address - Phone:973-857-0330
Practice Address - Fax:973-857-0980
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00452200363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0637751Medicaid