Provider Demographics
NPI:1962674465
Name:LIBERATO, MICHAEL VINCENT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:VINCENT
Last Name:LIBERATO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:1691 THE ALAMEDA
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2203
Mailing Address - Country:US
Mailing Address - Phone:408-287-7532
Mailing Address - Fax:408-287-0405
Practice Address - Street 1:201 29TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-3271
Practice Address - Country:US
Practice Address - Phone:916-446-6921
Practice Address - Fax:916-446-0640
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA19657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202ZOtherMEDICARE PTAN