Provider Demographics
NPI:1457431066
Name:DELLERBA, PETER R (NP)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:R
Last Name:DELLERBA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1676 SUNSET AVE
Mailing Address - Street 2:FAXTON 4TH FLOOR
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5416
Mailing Address - Country:US
Mailing Address - Phone:315-624-8110
Mailing Address - Fax:315-624-8115
Practice Address - Street 1:1676 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5416
Practice Address - Country:US
Practice Address - Phone:315-624-8110
Practice Address - Fax:315-624-8115
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300813363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01475956Medicaid