Provider Demographics
NPI:1376988154
Name:CUSUMANO, ANGELA (PA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:CUSUMANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:994 POLK AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-2018
Mailing Address - Country:US
Mailing Address - Phone:516-652-4946
Mailing Address - Fax:
Practice Address - Street 1:2318 31ST ST
Practice Address - Street 2:SUITE 320
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2765
Practice Address - Country:US
Practice Address - Phone:718-728-9822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant