Basic Information
| Provider Information | |||||||||
| NPI: | 1437347820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPOLO | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANGOVSKI | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RPA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3085 HARLEM RD | ||||||||
| Address2: | |||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168445600 | ||||||||
| FaxNumber: | 7168445750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3085 HARLEM RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168445600 | ||||||||
| FaxNumber: | 7168445050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 012155 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000529829001 | 01 | NY | BCBS OF WNY | OTHER | 9515038 | 01 | NY | IHA | OTHER | 00028229501 | 01 | NY | UNIVERA | OTHER | 01482255 | 05 | NY | MEDICAID | 080122000011 | 01 | NY | FIDELIS | OTHER |