Provider Demographics
NPI:1649647637
Name:CAMPANELLA, BIANCA (PA-C)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:CAMPANELLA
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 1:3031 79TH ST
Mailing Address - Street 2:APT 1
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1509
Mailing Address - Country:US
Mailing Address - Phone:917-213-6640
Mailing Address - Fax:
Practice Address - Street 1:3031 79TH ST
Practice Address - Street 2:APT 1
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1509
Practice Address - Country:US
Practice Address - Phone:917-213-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018981363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant