=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083309397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GIULIANO RICCARDO PUPO PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2023
-----------------------------------------------------
Last Update Date | 04/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5320 MILITARY RD
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14092-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-297-1701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7290 ERICA LN
-----------------------------------------------------
City | NORTH TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14120-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-909-7625
-----------------------------------------------------
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 | 029881
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------