Provider Demographics
NPI:1306858220
Name:ACERRA, PAUL (PA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:ACERRA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 OSBORNE RD
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3265
Mailing Address - Country:US
Mailing Address - Phone:505-885-2188
Mailing Address - Fax:505-885-6486
Practice Address - Street 1:2411 OSBORNE RD
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3265
Practice Address - Country:US
Practice Address - Phone:505-885-2188
Practice Address - Fax:505-885-6486
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM79PA-001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR13196Medicare UPIN
NMPA79001Medicare ID - Type Unspecified