MEDICARE: THOMAS J ANTONINI PA

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	363AS0400X	Surgical Physician Assistant	002613	NY

General Provider Information

NPI Number	:	1366419848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS J ANTONINI PA

Provider Business Mailing Address
First Line	:	750 E ADAMS ST
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13210-2342
Country	:	US
Telephone Number	:	315-436-2240
Fax Number	:	315-448-6126

Provider Business Practice Location Address
First Line	:	750 E ADAMS ST
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13210-2342
Country	:	US
Telephone Number	:	315-436-2240
Fax Number	:	315-448-6126

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

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	04/16/2008

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