Provider Demographics
NPI:1942275870
Name:CARACCIOLO, DOMINICK M (PA-C)
Entity type:Individual
Prefix:
First Name:DOMINICK
Middle Name:M
Last Name:CARACCIOLO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 MILITARY TRL
Mailing Address - Street 2:SUITE 303
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7801
Mailing Address - Country:US
Mailing Address - Phone:561-427-0860
Mailing Address - Fax:561-427-0870
Practice Address - Street 1:2055 MILITARY TRL
Practice Address - Street 2:SUITE 303
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7801
Practice Address - Country:US
Practice Address - Phone:561-427-0860
Practice Address - Fax:561-427-0870
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102467363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ47903Medicare UPIN
FLU5145Medicare ID - Type Unspecified