Provider Demographics
NPI:1447222773
Name:SALERNO, REBECCA A (PA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:A
Last Name:SALERNO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:MOSHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:36 THOMAS INDIAN SCHOOL DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:NY
Mailing Address - Zip Code:14081-9300
Mailing Address - Country:US
Mailing Address - Phone:716-532-5582
Mailing Address - Fax:716-532-5228
Practice Address - Street 1:36 THOMAS INDIAN SCHOOL DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:NY
Practice Address - Zip Code:14081-9300
Practice Address - Country:US
Practice Address - Phone:716-532-5582
Practice Address - Fax:716-532-5228
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00865247Medicaid
NY53221AMedicare ID - Type Unspecified
NY005700694OtherBLUE CROSS BLUE SHIELD
NY9512292OtherINDEPENDENT HEALTH