Provider Demographics
NPI:1881721876
Name:PERSAUD, MICHAEL K (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:PERSAUD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 E 78TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3307
Mailing Address - Country:US
Mailing Address - Phone:718-920-7401
Mailing Address - Fax:718-920-2058
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:MMC - DEPT OF MEDICINE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant