Healthcare Provider Details

I. General information

NPI: 1871484642
Provider Name (Legal Business Name): ANTONIO GIUSEPPE CICCOTTO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 SEGUINE AVE
STATEN ISLAND NY
10309-3932
US

IV. Provider business mailing address

11 CRESTON ST
STATEN ISLAND NY
10309-3534
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-2000
  • Fax:
Mailing address:
  • Phone: 917-932-4055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number033955
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: