Provider Demographics
NPI:1104875939
Name:CICCARELLI, ROBERT (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:CICCARELLI
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 1:4425 E COTTON CENTER BLVD
Mailing Address - Street 2:ALLRED COTTON CENTER, BUILDING 4
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-8854
Mailing Address - Country:US
Mailing Address - Phone:602-452-9801
Mailing Address - Fax:602-452-9852
Practice Address - Street 1:4425 E COTTON CENTER BLVD
Practice Address - Street 2:ALLRED COTTON CENTER, BUILDING 4
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-8854
Practice Address - Country:US
Practice Address - Phone:602-452-9801
Practice Address - Fax:602-452-9852
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102559Medicaid
AZR11728Medicare UPIN
AZ110300Medicare ID - Type Unspecified