Provider Demographics
NPI:1851556013
Name:LARICCIA, BRENTON JOSEPH (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:BRENTON
Middle Name:JOSEPH
Last Name:LARICCIA
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 PICTURESQUE DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-1005
Mailing Address - Country:US
Mailing Address - Phone:585-770-3642
Mailing Address - Fax:
Practice Address - Street 1:401 PICTURESQUE DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-1005
Practice Address - Country:US
Practice Address - Phone:585-770-3642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-26
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126422086S0102X
363AS0400X
NY012642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical