Provider Demographics
NPI:1023069101
Name:TOMASULO, DANIEL VICTOR (PA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:VICTOR
Last Name:TOMASULO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 SOUTHWESTERN BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1236
Mailing Address - Country:US
Mailing Address - Phone:716-675-0616
Mailing Address - Fax:716-675-7101
Practice Address - Street 1:3075 SOUTHWESTERN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1236
Practice Address - Country:US
Practice Address - Phone:716-675-0616
Practice Address - Fax:716-675-7101
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP71228Medicare UPIN
NYDD2896Medicare ID - Type UnspecifiedMEDICARE PROVIDER #