Provider Demographics
NPI:1710016795
Name:D'AMICO, DIANE (PA)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:D'AMICO
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 1:236 KING ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-6206
Mailing Address - Country:US
Mailing Address - Phone:718-948-3487
Mailing Address - Fax:718-226-2652
Practice Address - Street 1:1408 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2312
Practice Address - Country:US
Practice Address - Phone:718-226-2642
Practice Address - Fax:718-226-2652
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002341363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical