Provider Demographics
NPI:1366470692
Name:ANTONETTI, JORGE M (PA)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:M
Last Name:ANTONETTI
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:PO BOX 1351
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12301-1351
Mailing Address - Country:US
Mailing Address - Phone:518-470-4589
Mailing Address - Fax:
Practice Address - Street 1:1101 NOTT ST
Practice Address - Street 2:@ ELLIS HOSPITAL ER DEPT.
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2425
Practice Address - Country:US
Practice Address - Phone:518-243-4121
Practice Address - Fax:518-383-4223
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009973-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02619065Medicaid
NYPA0622Medicare ID - Type UnspecifiedINDV. PROVIDER #FOR GROUP
NY02619065Medicaid