Provider Demographics
NPI:1619700770
Name:COTUMACCIO, DOMINIC (PA)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:COTUMACCIO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-2920
Mailing Address - Country:US
Mailing Address - Phone:516-933-4350
Mailing Address - Fax:516-933-4352
Practice Address - Street 1:81 N BROADWAY
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-2920
Practice Address - Country:US
Practice Address - Phone:516-933-4350
Practice Address - Fax:516-933-4352
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NY363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical