Provider Demographics
NPI:1811070428
Name:TAURIELLO, MICHAEL DANIEL (PA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DANIEL
Last Name:TAURIELLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14 CHAUNCEY LN
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-3502
Mailing Address - Country:US
Mailing Address - Phone:631-379-4313
Mailing Address - Fax:
Practice Address - Street 1:205 FROEHLICH FARM BLVD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2931
Practice Address - Country:US
Practice Address - Phone:516-364-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010351-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ33708Medicare UPIN