Provider Demographics
NPI:1255570057
Name:SCICUTELLA, THOMAS NICHOLAS (PA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:NICHOLAS
Last Name:SCICUTELLA
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 1:8434 108TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1217
Mailing Address - Country:US
Mailing Address - Phone:347-886-9705
Mailing Address - Fax:
Practice Address - Street 1:121 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5425
Practice Address - Country:US
Practice Address - Phone:718-522-3000
Practice Address - Fax:718-522-0835
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010172363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMS13899243OtherDEA