Provider Demographics
NPI:1780158501
Name:IACOVIELLO, MICHELE CAMILLE (PA)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:CAMILLE
Last Name:IACOVIELLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WHEELER DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2645
Mailing Address - Country:US
Mailing Address - Phone:631-629-4696
Mailing Address - Fax:
Practice Address - Street 1:777 ZECKENDORF BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-2126
Practice Address - Country:US
Practice Address - Phone:516-832-8870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005017363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical