Healthcare Provider Details

I. General information

NPI: 1689067050
Provider Name (Legal Business Name): CAROL CUPOLO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 BROADWAY 6B23
BROOKLYN NY
11206-5317
US

IV. Provider business mailing address

208 EDWARD CT
WEST HEMPSTEAD NY
11552-2308
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-7956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002676
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: