Provider Demographics
NPI:1699037945
Name:ROTELLO, ANTHONY JAMES
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JAMES
Last Name:ROTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 SALINA MEADOWS PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4516
Mailing Address - Country:US
Mailing Address - Phone:315-464-2000
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:673 MDG, 5955 ZEAMER AVENUE
Practice Address - Street 2:
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-2306
Practice Address - Country:US
Practice Address - Phone:907-580-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056083363AM0700X
PAOA003028363AM0700X
OH50.003694363AS0400X
NY019047363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical