Provider Demographics
NPI:1356342299
Name:CICERO, MICHAEL CHRISTIAN (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHRISTIAN
Last Name:CICERO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 GATEWAY OAKS DR
Mailing Address - Street 2:STE 310
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-3658
Mailing Address - Country:US
Mailing Address - Phone:855-771-0335
Mailing Address - Fax:
Practice Address - Street 1:11930 HERITAGE OAK PL STE 9
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2458
Practice Address - Country:US
Practice Address - Phone:530-887-8785
Practice Address - Fax:530-887-8112
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29938ZMedicare ID - Type UnspecifiedGROUP MEDICARE ID
CA0PT239080Medicare ID - Type UnspecifiedINDIVID. PROVIDER ID