Provider Demographics
NPI:1760402994
Name:AMICO, JOHN (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:AMICO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2907
Mailing Address - Country:US
Mailing Address - Phone:703-293-9590
Mailing Address - Fax:703-293-9592
Practice Address - Street 1:575 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2634
Practice Address - Country:US
Practice Address - Phone:570-829-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN523008L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA084037Medicare PIN