Provider Demographics
NPI:1306382478
Name:DELLATACOMA, JANET (PA-C)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:DELLATACOMA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:
Other - Last Name:YE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1414 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3908
Mailing Address - Country:US
Mailing Address - Phone:718-447-1261
Mailing Address - Fax:718-981-1856
Practice Address - Street 1:1414 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3908
Practice Address - Country:US
Practice Address - Phone:718-447-1261
Practice Address - Fax:718-981-1856
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant