Provider Demographics
NPI:1720612880
Name:SICARDI, PETER JOSEPH JR
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOSEPH
Last Name:SICARDI
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 SILLS RD BLDG 18
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4808
Mailing Address - Country:US
Mailing Address - Phone:631-475-1224
Mailing Address - Fax:631-475-1588
Practice Address - Street 1:285 SILLS RD BLDG 18
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4808
Practice Address - Country:US
Practice Address - Phone:631-475-1224
Practice Address - Fax:631-475-1588
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025498-01363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical