Provider Demographics
NPI:1134564354
Name:AMICATERRA, GINA RAE (DPM)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:RAE
Last Name:AMICATERRA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:RAE
Other - Last Name:FREDERICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:455 MAPLE ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BIG FLATS
Mailing Address - State:NY
Mailing Address - Zip Code:14814-9701
Mailing Address - Country:US
Mailing Address - Phone:607-562-7300
Mailing Address - Fax:607-562-7575
Practice Address - Street 1:455 MAPLE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BIG FLATS
Practice Address - State:NY
Practice Address - Zip Code:14814-9701
Practice Address - Country:US
Practice Address - Phone:607-562-7300
Practice Address - Fax:607-562-7575
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNS006779-1213ES0103X
PWSC006714213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery