Provider Demographics
NPI:1417506361
Name:FUSCO, MICHAEL ANTHONY (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:FUSCO
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 1:6118 188TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2713
Mailing Address - Country:US
Mailing Address - Phone:718-489-5003
Mailing Address - Fax:
Practice Address - Street 1:6118 188TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2713
Practice Address - Country:US
Practice Address - Phone:718-489-5003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-008610363A00000X
363A00000X
NY024650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06011792Medicaid