Provider Demographics
NPI:1932449642
Name:VICIOSO, MICHAEL (PNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:VICIOSO
Suffix:
Gender:M
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3835 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-5303
Mailing Address - Country:US
Mailing Address - Phone:562-473-4441
Mailing Address - Fax:562-473-4447
Practice Address - Street 1:3835 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-5303
Practice Address - Country:US
Practice Address - Phone:562-473-4441
Practice Address - Fax:562-473-4447
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22745363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics