Provider Demographics
NPI:1629089834
Name:BISACCIA, ANTHONY F (PT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:F
Last Name:BISACCIA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NEWPORT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7501
Mailing Address - Country:US
Mailing Address - Phone:949-727-3315
Mailing Address - Fax:949-727-3624
Practice Address - Street 1:36 MAUCHLY
Practice Address - Street 2:STE A
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2393
Practice Address - Country:US
Practice Address - Phone:949-727-3315
Practice Address - Fax:949-727-3624
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 27358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT27358AMedicare PIN