Provider Demographics
NPI:1184718801
Name:PECORELLA, BRUCE T (PA)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:T
Last Name:PECORELLA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292A DUER ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126
Mailing Address - Country:US
Mailing Address - Phone:315-216-6347
Mailing Address - Fax:
Practice Address - Street 1:110 WEST SIXTH STREET
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-349-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011447363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400001030Medicare PIN