Provider Demographics
NPI:1336737550
Name:CAPPUCCI, MICHAEL ROY (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROY
Last Name:CAPPUCCI
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 1:1336 GOFFSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-2356
Mailing Address - Country:US
Mailing Address - Phone:774-437-9964
Mailing Address - Fax:
Practice Address - Street 1:185 QUEEN CITY AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-7121
Practice Address - Country:US
Practice Address - Phone:603-625-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1840363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical