Provider Demographics
NPI:1508116369
Name:SCOLARO, THERESA (PA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SCOLARO
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 1:833 NORTHERN BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5315
Mailing Address - Country:US
Mailing Address - Phone:516-238-2097
Mailing Address - Fax:
Practice Address - Street 1:40 LAUREL LN
Practice Address - Street 2:
Practice Address - City:LOCUST VALLEY
Practice Address - State:NY
Practice Address - Zip Code:11560-2204
Practice Address - Country:US
Practice Address - Phone:516-238-2097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015759363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical