Provider Demographics
NPI:1427587617
Name:ANTONELLI, LAURA-MARIE (PA)
Entity Type:Individual
Prefix:
First Name:LAURA-MARIE
Middle Name:
Last Name:ANTONELLI
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 1:39 WILCOX ST
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-3113
Mailing Address - Country:US
Mailing Address - Phone:201-575-1263
Mailing Address - Fax:
Practice Address - Street 1:701 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3723
Practice Address - Country:US
Practice Address - Phone:212-305-3605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant