Provider Demographics
NPI:1548755614
Name:BACCO, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BACCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14519 OTIS DR
Mailing Address - Street 2:
Mailing Address - City:NORTH HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:15642-1011
Mailing Address - Country:US
Mailing Address - Phone:412-592-4494
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-9800
Practice Address - Country:US
Practice Address - Phone:570-271-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical