Provider Demographics
NPI:1366874158
Name:IANNELLO, SAMANTHA (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:IANNELLO
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 1:4540 CENTER BLVD
Mailing Address - Street 2:APT 307
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11109-5792
Mailing Address - Country:US
Mailing Address - Phone:631-831-1917
Mailing Address - Fax:
Practice Address - Street 1:170 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2612
Practice Address - Country:US
Practice Address - Phone:212-312-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical