Provider Demographics
NPI:1114776325
Name:COLLAZO, CYNTHIA MARIA-FRANCESCA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIA-FRANCESCA
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:
Other - Last Name:COLLAZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COLLAZO,CYNTHIA PA
Mailing Address - Street 1:1880 WISTERIA CIR
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-3060
Mailing Address - Country:US
Mailing Address - Phone:347-256-9207
Mailing Address - Fax:934-451-3073
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-683-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical