Basic Information
| Provider Information | |||||||||
| NPI: | 1639453988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARZULLA | ||||||||
| FirstName: | AVERY | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 DATES DR | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072744011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 DATES DR | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072744011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 23 015101 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208M00000X | 015101 | NY | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 01995615 | 05 | NY | MEDICAID |