Provider Demographics
NPI:1902284813
Name:INGRASSIA, CAROL (CASAC)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:
Last Name:INGRASSIA
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:MRS
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:INGRASSIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CASAC
Mailing Address - Street 1:365 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HURLEYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12747-5440
Mailing Address - Country:US
Mailing Address - Phone:845-794-8080
Mailing Address - Fax:845-794-8343
Practice Address - Street 1:365 MAIN ST
Practice Address - Street 2:
Practice Address - City:HURLEYVILLE
Practice Address - State:NY
Practice Address - Zip Code:12747-5440
Practice Address - Country:US
Practice Address - Phone:845-794-8080
Practice Address - Fax:845-794-8343
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302F00000X302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization