Provider Demographics
NPI:1750300265
Name:HODGE-RANDAZZO, MELANIE A (PA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:A
Last Name:HODGE-RANDAZZO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:A
Other - Last Name:HODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 27842
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-7842
Mailing Address - Country:US
Mailing Address - Phone:718-670-1651
Mailing Address - Fax:516-437-4167
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-2384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009089363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00669Medicare PIN
NY6357DFMedicare PIN