Basic Information
| Provider Information | |||||||||
| NPI: | 1679987143 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CICCO | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5046 REVOLUTIONARY PATH | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704987688 | ||||||||
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| Practice Location | |||||||||
| Address1: | 736 IRVING AVE | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154707111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2014 | ||||||||
| LastUpdateDate: | 06/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 338748 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.