Healthcare Provider Details

I. General information

NPI: 1285946236
Provider Name (Legal Business Name): KRISTIN ANN CICALESE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 03/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONTAUK HWY
WEST ISLIP NY
11795-4927
US

IV. Provider business mailing address

12 MATINECOCK AVE
EAST ISLIP NY
11730-2617
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-4444
  • Fax:
Mailing address:
  • Phone: 631-664-5089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: