Provider Demographics
NPI:1124573381
Name:CICCONE, EMILIO (PA-C)
Entity type:Individual
Prefix:MR
First Name:EMILIO
Middle Name:
Last Name:CICCONE
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 1:130 S 22ND ST APT 1R
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-4351
Mailing Address - Country:US
Mailing Address - Phone:267-408-0506
Mailing Address - Fax:
Practice Address - Street 1:130 S 22ND ST APT 1R
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-4351
Practice Address - Country:US
Practice Address - Phone:267-408-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant