Provider Demographics
NPI:1952311052
Name:CANCILLA, MICHAEL ANTHONY JR (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:CANCILLA
Suffix:JR
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 1:2020 J ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-3120
Mailing Address - Country:US
Mailing Address - Phone:916-341-0576
Mailing Address - Fax:916-498-9040
Practice Address - Street 1:2020 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-3120
Practice Address - Country:US
Practice Address - Phone:916-341-0576
Practice Address - Fax:916-498-9040
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15366146D00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15366Medicaid
CAPA15366Medicaid
CAPA15366Medicaid