Provider Demographics
NPI:1649475021
Name:COLLADO, GIOSELY M (RPAC)
Entity type:Individual
Prefix:
First Name:GIOSELY
Middle Name:M
Last Name:COLLADO
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:MISS
Other - First Name:GIOSELY
Other - Middle Name:M
Other - Last Name:COLLADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPAC
Mailing Address - Street 1:3875 BROADWAY B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1567
Mailing Address - Country:US
Mailing Address - Phone:212-543-3110
Mailing Address - Fax:
Practice Address - Street 1:3867 BROADWAY LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1505
Practice Address - Country:US
Practice Address - Phone:212-543-3110
Practice Address - Fax:212-543-3111
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010342363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant