=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043562523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARA NICOLE COLASURDO PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2012
-----------------------------------------------------
Last Update Date | 08/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1176 5TH AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-6503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-241-4526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 TANNERS BROOK RD
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07930-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-219-7150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 016005-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------