Provider Demographics
NPI:1407402126
Name:SCRUDATO, MARIELLA R (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIELLA
Middle Name:R
Last Name:SCRUDATO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIELLA
Other - Middle Name:R
Other - Last Name:BILELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:65 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-1151
Mailing Address - Country:US
Mailing Address - Phone:516-622-3490
Mailing Address - Fax:
Practice Address - Street 1:65 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1151
Practice Address - Country:US
Practice Address - Phone:516-622-3490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant