Provider Demographics
NPI:1851450977
Name:RISELVATO, ROBERT ANTHONY (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ANTHONY
Last Name:RISELVATO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 LARKFIELD RD FL 2
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3131
Mailing Address - Country:US
Mailing Address - Phone:631-462-2225
Mailing Address - Fax:631-462-2804
Practice Address - Street 1:763 LARKFIELD RD FL 2
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3131
Practice Address - Country:US
Practice Address - Phone:631-462-2225
Practice Address - Fax:631-462-2804
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012994363AS0400X
NYP54292207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000Medicare UPIN