Provider Demographics
NPI:1801040126
Name:MARIDANIELLE D. ANNICCHIARICO, REGISTERED PHYSICIAN ASSISTANT-CERTIFIE
Entity Type:Organization
Organization Name:MARIDANIELLE D. ANNICCHIARICO, REGISTERED PHYSICIAN ASSISTANT-CERTIFIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIDANIELLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANNICCHIARICO
Authorized Official - Suffix:
Authorized Official - Credentials:RPA-C
Authorized Official - Phone:845-566-4595
Mailing Address - Street 1:PO BOX 10082
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12552-0082
Mailing Address - Country:US
Mailing Address - Phone:845-566-4595
Mailing Address - Fax:
Practice Address - Street 1:15 BLACK ANGUS CT
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-1567
Practice Address - Country:US
Practice Address - Phone:845-566-4595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005535-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty