Provider Demographics
NPI:1861825473
Name:CICCARELLI, BLAIR LEE (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:BLAIR
Middle Name:LEE
Last Name:CICCARELLI
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 1:427 GUY PARK AVE
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-1054
Mailing Address - Country:US
Mailing Address - Phone:518-841-7237
Mailing Address - Fax:
Practice Address - Street 1:427 GUY PARK AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1054
Practice Address - Country:US
Practice Address - Phone:518-841-7237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant