Provider Demographics
NPI:1578665733
Name:IANNOLI, ANDREA BURGE (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:BURGE
Last Name:IANNOLI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:ELIZABETH
Other - Last Name:BURGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1555 LONG POND RD
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4122
Mailing Address - Country:US
Mailing Address - Phone:585-723-7000
Mailing Address - Fax:585-723-7045
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-723-7000
Practice Address - Fax:585-723-7045
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011472363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02805338Medicaid
NYJ400088805/GRPBA0017Medicare PIN
NYJ400088804/GRP70008AMedicare PIN