Individual
MIA R DERICCO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
270 E MAIN ST, BAY SHORE, NY 11706-8420
(631) 591-7470
Mailing address
39 WOODLAND DR, SMITHTOWN, NY 11787-1847
(631) 848-2092
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
030197
NY
Other
Enumeration date
08/02/2023
Last updated
08/02/2023
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