Provider Demographics
NPI:1215010632
Name:SACCO, GLORIA REBECCA (PAC)
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:REBECCA
Last Name:SACCO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8268 164TH ST
Mailing Address - Street 2:MANAGED CARE, D1-01
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1121
Mailing Address - Country:US
Mailing Address - Phone:718-883-4007
Mailing Address - Fax:718-883-6295
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:718-883-4007
Practice Address - Fax:718-883-6295
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00330231Medicare ID - Type Unspecified