Provider Demographics
NPI:1124031240
Name:SPARACIO, ROBERT L (PA C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:SPARACIO
Suffix:
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:PO BOX 11090
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1090
Mailing Address - Country:US
Mailing Address - Phone:562-809-3548
Mailing Address - Fax:
Practice Address - Street 1:1296 NORTH AVE
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10804-2603
Practice Address - Country:US
Practice Address - Phone:914-235-8224
Practice Address - Fax:914-235-6940
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001354363AM0700X
NY012382363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4024972Medicaid
NY03036591Medicaid
CT4041679Medicaid
CT4024972Medicaid
NY11212EE791Medicare PIN
CT4041679Medicaid