Provider Demographics
NPI:1326395161
Name:COLLETTI, MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:COLLETTI
Suffix:
Gender:F
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 1:1275 YORK AVE
Mailing Address - Street 2:H1208
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6007
Mailing Address - Country:US
Mailing Address - Phone:212-639-5738
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:H1208
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-5738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015770-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant