Provider Demographics
NPI:1780221408
Name:MIRRA, MARIO J
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:J
Last Name:MIRRA
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 1:127 PLEASANTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13208-3144
Mailing Address - Country:US
Mailing Address - Phone:315-317-6161
Mailing Address - Fax:
Practice Address - Street 1:127 PLEASANTVIEW AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208-3144
Practice Address - Country:US
Practice Address - Phone:315-317-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)