Provider Demographics
NPI:1356975411
Name:MAZZOLA, MIMMA ALESSANDRA (PA-C)
Entity type:Individual
Prefix:
First Name:MIMMA
Middle Name:ALESSANDRA
Last Name:MAZZOLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2018 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-3216
Mailing Address - Country:US
Mailing Address - Phone:718-570-6889
Mailing Address - Fax:
Practice Address - Street 1:510 BROADHOLLOW RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3671
Practice Address - Country:US
Practice Address - Phone:631-424-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant