Provider Demographics
NPI:1245584101
Name:MAURO, MARINO ODENG (PA)
Entity Type:Individual
Prefix:MR
First Name:MARINO
Middle Name:ODENG
Last Name:MAURO
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Gender:M
Credentials:PA
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Mailing Address - Street 1:251 SALINA MEADOWS PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212
Mailing Address - Country:US
Mailing Address - Phone:315-464-2000
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:550 HARRISON STREET
Practice Address - Street 2:SUITE I
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202
Practice Address - Country:US
Practice Address - Phone:315-464-6527
Practice Address - Fax:315-464-1729
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2022-11-09
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Provider Licenses
StateLicense IDTaxonomies
NY016161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400136715Medicare PIN