Provider Demographics
NPI:1578568804
Name:BACERDO, MICHAEL V (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:V
Last Name:BACERDO
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BEEKMAN ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-1522
Mailing Address - Country:US
Mailing Address - Phone:212-513-7711
Mailing Address - Fax:212-964-4861
Practice Address - Street 1:19 BEEKMAN ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-1522
Practice Address - Country:US
Practice Address - Phone:212-513-7711
Practice Address - Fax:212-964-4861
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005310-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP93851Medicare UPIN
NY5088LIMedicare ID - Type UnspecifiedMEDICARE #