Provider Demographics
NPI:1699896001
Name:MICCIARIELLO, CHRISTINE MARIE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:MARIE
Last Name:MICCIARIELLO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MS
Other - First Name:CHRISTINE
Other - Middle Name:MARIE
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:
Practice Address - Street 1:325 ESSJAY RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8243
Practice Address - Country:US
Practice Address - Phone:716-631-2517
Practice Address - Fax:716-634-5650
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007098-1363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA1946Medicare PIN