Provider Demographics
NPI:1376737411
Name:MIGLIACCIO, GIANNI B (PA-C)
Entity Type:Individual
Prefix:
First Name:GIANNI
Middle Name:B
Last Name:MIGLIACCIO
Suffix:
Gender:M
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 1:800 TYDINGS LN
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-2102
Mailing Address - Country:US
Mailing Address - Phone:410-273-6600
Mailing Address - Fax:410-734-2305
Practice Address - Street 1:800 TYDINGS LN
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-2102
Practice Address - Country:US
Practice Address - Phone:410-273-6600
Practice Address - Fax:410-734-2305
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012255363AM0700X
MDC05654363A00000X
VA0110003850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02951164Medicaid
NY02951164Medicaid
PA2266 (70008A GROUPMedicare PIN
538695Medicare PIN