Provider Demographics
NPI:1790554988
Name:SACCO, ELISE (MSPAP, PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ELISE
Middle Name:
Last Name:SACCO
Suffix:
Gender:F
Credentials:MSPAP, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-4401
Mailing Address - Country:US
Mailing Address - Phone:909-593-3511
Mailing Address - Fax:
Practice Address - Street 1:1950 3RD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-4401
Practice Address - Country:US
Practice Address - Phone:909-593-3511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00826500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant