Provider Demographics
NPI:1821237611
Name:MIRABELLA, SANTA ANN MARIE (RPA-C)
Entity Type:Individual
Prefix:MS
First Name:SANTA
Middle Name:ANN MARIE
Last Name:MIRABELLA
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:ANN MARIE
Other - Middle Name:
Other - Last Name:MIRABELLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPA-C
Mailing Address - Street 1:23 WOOTTON ROAD
Mailing Address - Street 2:
Mailing Address - City:ESSEX FELLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07021
Mailing Address - Country:US
Mailing Address - Phone:917-734-3092
Mailing Address - Fax:
Practice Address - Street 1:1504 RICHMOND ROAD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304
Practice Address - Country:US
Practice Address - Phone:718-667-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005789-1363A00000X
NJ25MP00063600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant