MEDICARE: EDWARD COLUCCI RPA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	015394-1	NY

General Provider Information

NPI Number	:	1104196336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD COLUCCI RPA-C

Provider Business Mailing Address
First Line	:	18 ROME AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-4318
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1421 E 2ND ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-5501
Country	:	US
Telephone Number	:	718-645-7337
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2012
Last Update Date	:	01/04/2012

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