Provider Demographics
NPI:1114464153
Name:SOUSA, MICHAEL JOSEPH II (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:SOUSA
Suffix:II
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 E NASSAU ST
Mailing Address - Street 2:
Mailing Address - City:ISLIP TERRACE
Mailing Address - State:NY
Mailing Address - Zip Code:11752-3004
Mailing Address - Country:US
Mailing Address - Phone:631-398-1808
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-29
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020590363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant