Provider Demographics
NPI:1235598178
Name:DAMIANO, ELLYSE (PA)
Entity Type:Individual
Prefix:
First Name:ELLYSE
Middle Name:
Last Name:DAMIANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELLYSE
Other - Middle Name:
Other - Last Name:CIPRIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:285 SILLS RD STE D
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4869
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 SILLS RD STE D
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4869
Practice Address - Country:US
Practice Address - Phone:631-438-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-21
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant