Basic Information
Provider Information | |||||||||
NPI: | 1306968243 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMALL-CANGIALOSI | ||||||||
FirstName: | SHIRA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMALL-CANGIALOSI | ||||||||
OtherFirstName: | SHIRA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1 ATWELL RD | ||||||||
Address2: |   | ||||||||
City: | COOPERSTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 133261301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6075473480 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 739 STATE HIGHWAY 28 STE 9 | ||||||||
Address2: |   | ||||||||
City: | ONEONTA | ||||||||
State: | NY | ||||||||
PostalCode: | 138203590 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6074311015 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2007 | ||||||||
LastUpdateDate: | 10/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 007426 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.