Provider Demographics
NPI:1659318947
Name:COLEMAN-SPICIATI, COLLEEN BETH (PA)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:BETH
Last Name:COLEMAN-SPICIATI
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 1:591 W JERICHO TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-360-5900
Mailing Address - Fax:
Practice Address - Street 1:519 W JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2619
Practice Address - Country:US
Practice Address - Phone:631-360-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5F13371801Medicare PIN
NYP54680Medicare UPIN
NY008173Medicare ID - Type Unspecified