Provider Demographics
NPI:1215761697
Name:POLLINO, MIA NICHOLLE (PA-C)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:NICHOLLE
Last Name:POLLINO
Suffix:
Gender:F
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 1:3780 RIVERS POINTE WAY APT 8
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-4953
Mailing Address - Country:US
Mailing Address - Phone:315-521-2429
Mailing Address - Fax:
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5011
Practice Address - Fax:315-492-5973
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant