Provider Demographics
NPI:1689123614
Name:MARTIN, ANGELICA PASCONE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:PASCONE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:BRITTNEY
Other - Last Name:PASCONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2209 GENESEE ST.
Mailing Address - Street 2:BUSINESS OFFICE ROOM 310
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501
Mailing Address - Country:US
Mailing Address - Phone:315-801-3282
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:2215 GENESEE ST.
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501
Practice Address - Country:US
Practice Address - Phone:315-801-3484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020214363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04606039Medicaid