Provider Demographics
NPI:1255772232
Name:RIZZUTO, MICHAEL J (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:RIZZUTO
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 1:123 EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1407
Mailing Address - Country:US
Mailing Address - Phone:518-701-2086
Mailing Address - Fax:518-701-2139
Practice Address - Street 1:123 EVERETT RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1407
Practice Address - Country:US
Practice Address - Phone:518-701-2000
Practice Address - Fax:518-701-2020
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016591363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03609703Medicaid
NYJ400090821Medicare PIN