Healthcare Provider Details

I. General information

NPI: 1104875939
Provider Name (Legal Business Name): ROBERT CICCARELLI P.A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 E COTTON CENTER BLVD ALLRED COTTON CENTER, BUILDING 4
PHOENIX AZ
85040-8854
US

IV. Provider business mailing address

4425 E COTTON CENTER BLVD ALLRED COTTON CENTER, BUILDING 4
PHOENIX AZ
85040-8854
US

V. Phone/Fax

Practice location:
  • Phone: 602-452-9801
  • Fax: 602-452-9852
Mailing address:
  • Phone: 602-452-9801
  • Fax: 602-452-9852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1323
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: