Provider Demographics
NPI:1649255571
Name:IACONA-CARBONELLA, DANIELA (PA)
Entity type:Individual
Prefix:
First Name:DANIELA
Middle Name:
Last Name:IACONA-CARBONELLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DANIELA
Other - Middle Name:
Other - Last Name:IACONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4433
Mailing Address - Fax:504-842-9725
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2429
Practice Address - Country:US
Practice Address - Phone:504-842-4433
Practice Address - Fax:504-842-9725
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007026363AM0700X
LA303788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00632777Medicaid
LA2438255Medicaid
NY02055672Medicaid
NY02055672Medicaid
NYA400034128Medicare PIN