Provider Demographics
NPI:1841724929
Name:BACALSO, MYLA GUANGCO
Entity type:Individual
Prefix:
First Name:MYLA
Middle Name:GUANGCO
Last Name:BACALSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYLA
Other - Middle Name:BACALSO
Other - Last Name:DUCUSIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:248-577-3313
Mailing Address - Fax:248-577-3302
Practice Address - Street 1:50083 MARGARET AVE
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-6340
Practice Address - Country:US
Practice Address - Phone:586-412-0838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704200259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily