Provider Demographics
NPI:1639503410
Name:MASCIELLO, MICHAELA AILEEN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:MICHAELA
Middle Name:AILEEN
Last Name:MASCIELLO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:29 DUNLOP CT
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1774
Mailing Address - Country:US
Mailing Address - Phone:516-971-3315
Mailing Address - Fax:
Practice Address - Street 1:280 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8403
Practice Address - Country:US
Practice Address - Phone:631-591-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY016893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant