Provider Demographics
NPI:1578615621
Name:CIVITANO, MARC THOMAS (PA)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:THOMAS
Last Name:CIVITANO
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Gender:M
Credentials:PA
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Mailing Address - Street 1:600 MAMARONECK AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-1635
Mailing Address - Country:US
Mailing Address - Phone:914-686-0111
Mailing Address - Fax:914-686-8964
Practice Address - Street 1:600 MAMARONECK AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-1635
Practice Address - Country:US
Practice Address - Phone:914-686-0111
Practice Address - Fax:914-686-8964
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2013-07-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY011059363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400067606Medicare PIN
NYA400022322Medicare PIN