Healthcare Provider Details

I. General information

NPI: 1679987143
Provider Name (Legal Business Name): PHILLIP MARTIN CICCO N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 IRVING AVE
SYRACUSE NY
13210-1687
US

IV. Provider business mailing address

5046 REVOLUTIONARY PATH
LIVERPOOL NY
13088
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7111
  • Fax:
Mailing address:
  • Phone: 570-498-7688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number338748
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: