Provider Demographics
NPI:1184807398
Name:MICHAEL, ALFRED (PA-C)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PROSPECT AVE
Mailing Address - Street 2:CLINICAL AFFILIATES
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1807
Mailing Address - Country:US
Mailing Address - Phone:315-448-2713
Mailing Address - Fax:315-448-6325
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:CLINICAL AFFILIATES
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-448-2713
Practice Address - Fax:315-448-6325
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011988363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
J400018228Medicare PIN