Provider Demographics
NPI:1811181233
Name:PICOZZO, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PICOZZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:OLYPHANT
Mailing Address - State:PA
Mailing Address - Zip Code:18447-1475
Mailing Address - Country:US
Mailing Address - Phone:570-383-3636
Mailing Address - Fax:
Practice Address - Street 1:221 RIVER ST
Practice Address - Street 2:
Practice Address - City:OLYPHANT
Practice Address - State:PA
Practice Address - Zip Code:18447-1475
Practice Address - Country:US
Practice Address - Phone:570-383-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATMA051761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant