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NPI Code Detail

MEDICARE: LAURA-MARIE ANTONELLI PA

MEDICARE: LAURA-MARIE ANTONELLI 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
1363A00000XPhysician Assistant

General Provider Information

NPI Number : 1427587617
Entity Type Code : Individual
Provider Name (Legal Business Name) : LAURA-MARIE ANTONELLI PA
Provider Business Mailing Address
First Line : 39 WILCOX ST
Second Line :
City : DUMONT
State : NJ
Zip : 07628-3113
Country : US
Telephone Number : 201-575-1263
Fax Number :
Provider Business Practice Location Address
First Line : 701 W 168TH ST
Second Line :
City : NEW YORK
State : NY
Zip : 10032-3723
Country : US
Telephone Number : 212-305-3605
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/09/2017
Last Update Date : 06/09/2017

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Directions to “ LAURA-MARIE ANTONELLI PA” Practice Location

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