Healthcare Provider Details

I. General information

NPI: 1457860124
Provider Name (Legal Business Name): CARRIE CERINO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE LERGNER PA

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 DRIVING PARK AVE
NEWARK NY
14513
US

IV. Provider business mailing address

1200 DRIVING PARK AVE
NEWARK NY
14513-1090
US

V. Phone/Fax

Practice location:
  • Phone: 315-332-2022
  • Fax:
Mailing address:
  • Phone: 315-359-2656
  • Fax: 315-359-2699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number021403
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: