Provider Demographics
NPI:1225055890
Name:PERICAK, ARLENE (NP)
Entity Type:Individual
Prefix:MR
First Name:ARLENE
Middle Name:
Last Name:PERICAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:942A ROUTE 146
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3614
Mailing Address - Country:US
Mailing Address - Phone:518-371-8000
Mailing Address - Fax:518-371-5338
Practice Address - Street 1:942A ROUTE 146
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3614
Practice Address - Country:US
Practice Address - Phone:518-371-8000
Practice Address - Fax:518-371-5338
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330373-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY671204OtherGHI-HMO
NY120118000008OtherFIDELIS
NY02408120Medicaid