Provider Demographics
NPI:1154588929
Name:DARGE, ALICIA (RPAC)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:DARGE
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8403
Mailing Address - Country:US
Mailing Address - Phone:631-591-7400
Mailing Address - Fax:631-591-7401
Practice Address - Street 1:280 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8403
Practice Address - Country:US
Practice Address - Phone:631-591-7400
Practice Address - Fax:631-591-7401
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant