Provider Demographics
NPI:1497291926
Name:MACINO, VINCENT (PA)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:MACINO
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 1:840 IRVING ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-2311
Mailing Address - Country:US
Mailing Address - Phone:415-590-6140
Mailing Address - Fax:412-529-1048
Practice Address - Street 1:181 W MADISON ST STE 3825
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-4500
Practice Address - Country:US
Practice Address - Phone:415-658-6791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-08
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54322363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant