Provider Demographics
NPI:1245290626
Name:CICCHINO, DENNIS B (PA)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:B
Last Name:CICCHINO
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:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12181-0689
Mailing Address - Country:US
Mailing Address - Phone:518-268-5000
Mailing Address - Fax:
Practice Address - Street 1:2 EMPIRE DR
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144-5730
Practice Address - Country:US
Practice Address - Phone:518-286-4899
Practice Address - Fax:518-286-4859
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01819910Medicaid
S50645Medicare UPIN
NYBB0070Medicare PIN