Healthcare Provider Details

I. General information

NPI: 1023420247
Provider Name (Legal Business Name): MARISA DAGOSTINO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 TROY SCHENECTADY RD STE 101
LATHAM NY
12110-1074
US

IV. Provider business mailing address

2215 BURDETT AVE EMERGENCY DEPARTMENT
TROY NY
12180-2466
US

V. Phone/Fax

Practice location:
  • Phone: 518-348-3176
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: