Provider Demographics
NPI:1174545990
Name:LOCCISANO, ANTOINETTE (PA)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:LOCCISANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:
Other - Last Name:LOCCISANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:C/O EMERGENCY PRACTICE PLAN
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11352
Mailing Address - Country:US
Mailing Address - Phone:610-668-6491
Mailing Address - Fax:610-617-6280
Practice Address - Street 1:56-45 MAIN STREET
Practice Address - Street 2:NEW YORK HOSPITAL MEDICAL CENTER OF QUEENS - EMERGENCY
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-670-1231
Practice Address - Fax:610-617-6280
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S94415Medicare UPIN
NY6383ULMedicare ID - Type Unspecified