Provider Demographics
NPI:1982683934
Name:MARINO, CYNTHIA M (PA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:MARINO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:M
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1722
Mailing Address - Country:US
Mailing Address - Phone:585-905-0061
Mailing Address - Fax:585-412-6612
Practice Address - Street 1:3200 WEST ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1722
Practice Address - Country:US
Practice Address - Phone:585-905-0061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002173364SP0808X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0107647OtherINDEPENDENT HEALTH
NY000570164004OtherCOMMUNITY BLUE
NY0107647OtherINDEPENDENT HEALTH
NY000570164004OtherCOMMUNITY BLUE