Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | X012117-1 | NY |
NPI | 1629348941 |
---|---|
Provider Name | Dr. Michael Anthony Persoleo JR. |
First Address | Ithaca, NY 14850-1320 |
Second Address | Ithaca, NY 14850-4027 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2012 |
Last Update Date | 03/01/2012 |