Provider Demographics
NPI:1316600745
Name:BACCHUS, MICHELLE ROZANA (PA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ROZANA
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:266 PONTIAC PL
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 ROCKAWAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1666
Practice Address - Country:US
Practice Address - Phone:516-887-4343
Practice Address - Fax:516-887-8569
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY011819363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant