Provider Demographics
NPI:1811391584
Name:AZZARELLO, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:AZZARELLO
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 1:3176 ABBOTT RD
Mailing Address - Street 2:BUILDING A, SUITE 500
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1069
Mailing Address - Country:US
Mailing Address - Phone:716-822-2177
Mailing Address - Fax:716-822-8165
Practice Address - Street 1:3176 ABBOTT RD
Practice Address - Street 2:BUILDING A, SUITE 500
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1069
Practice Address - Country:US
Practice Address - Phone:716-822-2177
Practice Address - Fax:716-822-8165
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22 500058163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse