Healthcare Provider Details

I. General information

NPI: 1659646065
Provider Name (Legal Business Name): MICHAEL ANTHONY CARUSO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9768 LIBERTY DR
PAINTED POST NY
14870-9094
US

IV. Provider business mailing address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

V. Phone/Fax

Practice location:
  • Phone: 607-937-4900
  • Fax: 607-937-4940
Mailing address:
  • Phone: 570-888-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019870
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: