MEDICARE: GIOSELY M COLLADO RPAC

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	363A00000X	Physician Assistant	010342	NY

General Provider Information

NPI Number	:	1649475021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GIOSELY M COLLADO RPAC

Provider Business Mailing Address
First Line	:	3875 BROADWAY B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10032-1567
Country	:	US
Telephone Number	:	212-543-3110
Fax Number	:

Provider Business Practice Location Address
First Line	:	3867 BROADWAY LOWR LEVEL
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10032-1505
Country	:	US
Telephone Number	:	212-543-3110
Fax Number	:	212-543-3111

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

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	12/30/2015

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